Embarrassment after a med error

allnurses Guide · Jan 9, 2017

I just made an error this past weekend. I was mortified. I was ashamed. My assignment was chaotic and, yes, we were understaffed... this, in turn, made me angry.

HOWEVER, I made the mistake and I owned it. I notified the charge, doctors and others who needed to be aware. I monitored my patient.

My mistake was an easy mistake to make and, thankfully, caused no harm. Still, any mistake is serious and shouldn't be minimized. I could have just as easily made a dangerous one.

Med errors happen to everyone at some point. Doing the right thing afterward is important. This includes assessing the situation and what went wrong... so you don't do it again.

You are not alone... not by a long shot.

quazar · Jan 9, 2017

Yes, I've made a med error, yes I was mortified, yes I reported it to my charge nurse and the patient's physician immediately and filled out the proper paperwork.

No harm came to the patient, and both the charge nurse and the doctor were nonplussed by the error, but it was an error all the same. I felt horrible.

Ruby Vee, BSN · Jan 9, 2017

Hi everyone,
Here's some background: I am about to enter my 4th semester as a nursing student. I am starting my first clinical rotation next month. I work as a nursing assistant at a psychiatric hospital, on a voluntary unit.
The nurses are only there during week days, so the nursing assistants give medications when the nurses arent there. The daily meds are pre poured into cassettes. I have been giving meds for about 6 months now and have not made any errors because the process is not confusing. However, the other night was a crazy night with a lot going on. As I was giving a patient their med, they were asking for a PRN and a variety other things so I asked them to wait a second so I could get their daily meds first. Without thinking, I poured the AM meds into the cup and gave it to them. SO, I gave them their AM meds when they were supposed to receive their PM meds. The AM med was an antidepressant. I noticed as soon as she swallowed the pill. I called the nurse and essentially freaked out. She explained that she, too has made med errors and that it happens. The patient was completely fine, thankfully. I was instructed to give her PM med as well. Her AM med was very low dose so they said there would be no side effects. She was fine. But, I cannot stop beating myself up about this. The nurse said that the protocol for med errors is I have to sit down and talk to them about it and if they decide it's necessary, I may not be able to give meds for a little bit. I barely slept last night and I feel sick to my stomach. Another coworker has given the wrong meds to the wrong patient and they had a negative rx to it, so in comparison thankfully mine was not the wrong patient but it's the principle that I made the error.
I'm one of the few workers who is in nursing school and I am so embarrassed that I was one to make a med error. I typically always go over the 5 Rights in my head but I failed to do so that night. One things for sure, I do not think I will ever make that error again as now I am going to be over cautious. I'm also worried about the other nurses' opinions of me may change, as I was respected prior to this for always being on my A game at work. I'm so embarrassed.
Have any nurses on here made a similar med error, or one at all? I'm now questioning myself and my abilities. Any advice for how to handle this embarrassment?

Everyone makes mistakes; absolutely everyone. No one is perfect. Everyone who passes meds has made a medication error. Anyone who tells you they've never made a medication error is either lying or too stupid to realize that they've made one. Congratulations! You are neither a liar nor stupid. The difference between a good nurse and a bad nurse is not in whether or not they've made an error; the difference is what they do after they've made the error. From what I'm reading here, you will be one of the good ones.

First, you have to recognize that you've made an error -- some folks lack that capacity, and they shouldn't be nurses. Then, you have to admit it to yourself and to everyone else who needs to know. (That includes calling the prescriber and asking for a plan or for orders.). Immediately set about mitigating the damage to the patient -- if you've given too much insulin, check blood glucoses and be ready to give sugar, whether it be D50 or regular Coke. Too much potassium, perhaps you'll give insulin and D50, maybe you'll be calling the dialysis nurse or maybe you'll just check frequent K+ levels and then decide. There is almost always an "antidote" and patients are incredibly resilient in surviving such incidents.

And finally, when the patient is as safe as you can make him or her, contact your nurse manager. Walk into her office, call her, email her, text her -- whatever you need to do. You want her to find out about the error from you, not from some upper management or physician complaining about the "incompetent staff." Make sure she understands that you recognized you error, that you are incredibly, deeply sorry because you understand that the consequences to your patient could have been devastating. (Even it it's a late Colace, the consequences could have been devastating if it had been a different medication and you hadn't recognized your error, right? For those other than the OP who are reading this, NEVER minimize or rationalize. You don't get points because "no one was harmed." A good manager will recognize the minimizing and rationalizing and wonder what you'll be saying the next time or the one after that when someone IS harmed.). If you've had time to consider it, tell your manager what you think caused you to make the error and how you plan to prevent it from ever happening again.

Then forgive yourself. Give yourself some kudos for doing the right thing because that is the difference between a good nurse and a bad one. Forgiving yourself is the hardest part for the good nurses, but if you don't manage to forgive yourself, you set yourself up to be tense and anxious every time you pass meds which increases the possibility of another error. Don't get trapped in that cycle.

There's a thread out there about the "Worst Med Error I've Ever Made" (or something like that). There are some doozies in there; even some of mine.

Jules A, MSN · Jan 10, 2017

Been there done that. It will be ok and I applaud you for handling it the proper way. The good news is your patient is unharmed and I guarantee you won't ever make that exact same error again. Forgive yourself and remember this lesson.

Longleggedstar · Jan 12, 2017

Let me tell you a secret: Any nurse who passes meds on a consistent basis who says they have never made a med error...Is lying. Shhhhh...