dazed and confused....and worried

begalli · Feb 15, 2005

I guess what happens depends on your hospital.

Several years ago, when I was still new, I forgot to pop a cap (no, I'm not a gangsta) on a bag of nipride that actually activates the medication in the D5W. The nurse who followed me couldn't understand why the patient's pressure was not responding to the med as she titrated it up and up and up until she took the bag down and felt that the seal had not been broken on the med.

The patient was not harmed but there was potential for harm. There was an incident report written about this, and RIGHTFULLY so. I was devastated and my NM did have a discussion with me about it. Lesson learned for SURE! That was my first and only (so far) med error. Also, shortly after this incident, the pharmacy quit using these types of drips. ALL drips come premixed now.

xmaxiex · Feb 15, 2005

Oh my heart goes out to you ! I think everyone who has been a nurse can feel your pain . We do so much in one shift , it is hard to remember everything that occurs . I hope everything works out okay and I don't think this is something you should get fired for . But that depends on the facility you work in . Good Luck .

lissyrn · Feb 15, 2005

Thanks for the encouraging words.

My facility is a small rural hospital with a good union, and pretty cool mgrs, as mgrs go. I think what bothers me the most is...what exactly happened? It's unlikely that those meds had been sitting there for the prior 3 shifts with no one noticing them, but , on the other hand, I cannot believe that I could have done such a dumb thing. :smackingf I am always extremely meticulous with meds. (not always with everything, but certainly with meds).......

ktwlpn, LPN · Feb 15, 2005

The other night, I got a phone call at home from the evening shift saying that Mrs. F's unopened am meds were on the bedside table, not given. The eve nurse asked me, "did Mrs. F get her meds this morning"...and I was so flustered and surprised that all I could blurt out was a weak "I'm pretty sure".
Well, we get our meds out of a computerized system, and reports were run, and they see that I did pull this patient's meds out of the machine, only once. I could swear on my life that I gave this patient her meds. I don't recall at all being called away in the middle of giving them (I would never leave the meds at the bedside in any case--I never have)....I am totally perplexed.
Maybe I'm just having a severe stress meltdown and really did leave the room without giving her the meds. If this is what mgmt determines what happened, do you think it is cause for termination? Or just one of those " non-punitive" med error reports?
Has anything like this ever happened to anyone else?

yikes-I feel for you....Could those have been left from the morning prior? Really no way to prove it was you..But you could have had a brain fart-I pulled percocet out of the narc box once and took one for the pt and threw the rest away.....At shift's end when we discovered a problem and started backtracking I swore up and down that I could NOT have down that....of course,I did.....Luckily the hospital has a pretty good method for boxing clean waste-I almost fainted when the housekeeper opened that box of trash and the percs were lying in there as pretty as you please.....

Tweety, BSN, RN · Feb 15, 2005

I can relate. Sometimes my work gets like driving. I start out and suddenly I'm pulling up to my garage wondering how I got from point A to B and don't remember a thing.

11:11 · Feb 16, 2005

When giving PO meds I always stay there and make sure they take them. Most of my pts this isnt an issue because they cant take PO to begin with.

Nowadays I hand the meds to them in the cup and watch. If they are offended I just tell them its policy (mine).

Then I sign off the MAR, not before.

If theres a crisis I put them in my pocket then come back. Same goes for narcs. I never leave them out-

11

DutchgirlRN, ASN, RN · Feb 16, 2005

LissyRN, Everyone makes mistakes and although I think it's serious to leave medication at a patients bedside the patient wasn't hurt. I would think your employer would take this into consideration along with the fact that you have a clean record. I know my employee would just call you into the office for a quick verbal warning to be more careful. I put a check mark next to the patients name on my worksheet after they have taken their meds. And another checkmark after I have charted their assessment. Things can get so wild so fast and unpredictably that I had to work out a system to keep myself in check.