Well, I finally made a big medication error.

  1. So, just got home from work and probably won't sleep too well tonight because I just made a rather large med error. Had a two week old come in with a 101.6 rectal temp. I get a far more experienced nurse to come and help with IV, foley, etc., as I didn't feel it would be safe for me to attempt to care for this baby on my own. So we draw labs, get urine, and do an LP. After the LP, the MD orders two abx (300 mg cefotaxime and 300 mg ampicillin) and a 120 ml NS bolus. I double check my math for how many ml's I need to infuse with another nurse (we don't have 24 hr pharmacy) and hang both, get them infused before I take her to the peds unit. Also, the MD orders 90 mg Tylenol PO. I grab that before I take her up as well. Baby is looking/acting far better and I take her to the floor with Mom.

    Well, about an hour later, the peds nurse calls and says she is getting a weight of 3.52 kg, compared to our 6.1 kg. Apparently, the triage nurse had charted the weight wrong from the scale (charting lbs as kg) and it was never caught by myself or the doc.

    We ran through the dosages for the meds we gave and, according to the mg/kg/day amounts, we are in the safe range. However, I feel absolutely horrible about all this right now. I'm usually extremely careful with dosages, especially with babies, but somehow the weight just not looking right didn't ever click in my head. I think not having to do any dosage calculations myself helped me to not catch the weight error, but that's still no excuse for this to have happened. I feel AWFUL.

    I guess the point of this thread is to sort of vent my frustration with myself. I dunno. Anyone had a similar situation occur?
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    About brainkandy87

    Joined: Sep '10; Posts: 326; Likes: 563


  3. by   heparinized
    Im sorry to hear about the med error. I have been in the same boat but eversince then, I learned a lesson that made m OCD about my meds. I double check triple check before I go to my instructor for the med check offs. I have 3 months left until finished though we are doing team nursing where our team leader/charge nurse checks off our meds, I still triple check my meds.

    It's understandable that you'd feel horrible. But it was not entirely your fault. I want to share my horrible, my very first med error that caused somebody to stay one full day in the Psych ward.

    I was doing my special rotation in Mental Health, and there was these two gentlemen with BOTH SAME NAME and MIDDLE INITIALS, (so, tell me about it!) there MAR should have pictures of the gentlemen but for some reason, both of the pictures of the gentlemen were missing, and yes!, I should have identify the patients before, but I was in going through a very complicated phase of my marriage so I was totally not myself. The gentleman I gave the meds who's not suppose to be his, is also discharged that day, but of course this dummy nurse caused him to stay one more day for the nurses and docs to monitor him for any adverse effects. However, luckily this men receives 3 meds that the other gentleman is also taking, but the rest are like supplements and a blood pressure medicine.

    I felt so petrified for myself for making this unacceptable mistake, and embarrassed about my act to my fellow student nurses from what I just did. But you know, I take my lick and just move on. There will never be a perfect nurse. If somebody had told you s/he doesn't make mistake, s/he is lying.

    You'll be fine sweetheart. Just turn, cough it out, and deep breath. (wink*)
  4. by   Pixie.RN
    You did nothing wrong with your calculations ... I'd say that you just might just want to double-check weights for yourself on the little-bitties in the near-term, for your own peace of mind. I know it's tough when you're doing a septic workup on a tiny one, and time is of the essence as far as getting the test done and abx on board. And your triage nurse failed you. This is why one of our docs has a complete cow if we even dare to write lbs on the chart anywhere -- some triage nurses will write the lbs, then write the kg after conversion. I don't even write the lbs, just out of habit and for reasons like this. Now, could I look at a baby and tell you the weight? No. I am a horrible weight guesstimator. I have to trust my triage nurse to have the weight correct.

    *hugs* I'm sorry ... and glad that the outcome was okay.
  5. by   BostonTerrierLoverRN
    Well you just proved you are human. I really hate this happened. I can tell from your other posts that you are conscientious in your decision making, and this will be a huge stepping stone for you. You will probably never miss another "out-of-place" weight, and I appreciate you sharing this- you'll never know how many other nurses you have helped by posting this (Know that doesn't make you feel better right now). But, that said, just as the above post says- raise cane when you see a Pound Wt. on a Pediatric Chart.

    Awesome to hear they were in Safe Dose Ranges too. Hope you feel better soon.
  6. by   emtb2rn
    Terrifying. Glad to hear the dosing was wnl. Agree that the triage rn screwed up big time. Inexcusable. I'd have a word (or 2) with him/her about this incident.
  7. by   OnlybyHisgraceRN
    Everyone makes mistakes. You learned from your mistake. Some times we have nursing angels to watch over us. Even though it could have been catatrophic I believe God stepped in and made everything okay.
  8. by   ♪♫ in my ♥
    This also points out the value of practicing estimating weights... a 10 kg kid is twice as big as a 10 lb kid.

    Happy for you and for the patient that this was a harmless medication error.
  9. by   hiddencatRN
    I once went in to give a med to a patient, and charted as I was going in to the room that it was given. I got distracted while in the room, set the med down, handled a patient issue, and then walked out, leaving the med in the room unadministered. LUCKILY it was caught in the next shift and they figured out what had happened and administered the med but I felt TERRIBLE about it when I found out what had happened. Focus on the fact that you were within the safe range, and use it as a learning experience. THIS patient wasn't harmed, which is great, but maybe the next patient would have been?

    I'm terrible about estimating weights, but I've started to try to look at the patient with the weight when I weigh them to begin to build a personal reference for what X kg looks like. Turns out we're expected to be weight genies!
  10. by   LindseyRN86

    Take a deep breath. Everyone makes mistakes. Thankfully the little one wasn't hurt. I bet you will be triple checking from now on. It's a learning experience. Don't be too hard on yourself. Take care!

    P.S. I'm not perfect either I gave the wrong med to the wrong patient in my old LTC position because I let people talk to me while I was passing meds. Thankfully, it wasn't something that would hurt someone and luckily I found the error myself and took steps right away to monitor pt and call the Dr. and there was no adverse effects. After that I triple checked my patient med and wouldn't let anyone talk to me while administering meds. I felt awful but had to move on and pull up my boot straps.
  11. by   Altra
    Quote from ♪♫ in my ♥
    This also points out the value of practicing estimating weights... a 10 kg kid is twice as big as a 10 lb kid.

    Happy for you and for the patient that this was a harmless medication error.

    A 2-week old will be not much bigger than his/her birth weight. What's an average birth weight? What was this particular kiddo's birth weight, and was he/she a full-term infant? These are standard triage/assessment questions for a patient this age.

    With a little time, these are the kinds of "big picture" things that will pop into your head which help to prevent errors.
  12. by   ertlbsn
    Hi everyone,
    I am a newbie here, i am in a bsn program now.
    You guys have no idea how much you help newbie like me and others by these posts !
    I learn so much everyday from everyone here and i am so greatful for that too.

    BIG "THANK YOU" for such posts...again...I LEARN SO MUCH FROM EVERYONE HERE

  13. by   Esme12
    We all make mistakes. I know you are going to beat yourself up but it is the mistakes that will help make you the nurse you are and will become.

    Peds is my soap box. It drives me nuts when I hear people say that they want to work Peds because it is easy and the babies are so cute...that they just love babies. Peds is very specialized and you must be very careful as small mistakes can have BIG consequences. The room for error is very small. The nurse who weighed the infant was at fault for not clearly labeling what the 6 was.....pounds or kilos.

    I remember I was supervising and I was called to start an IV on 7 year old with septic arthritis. I started the IV and when I went to start the antibiotic I looked at the dose and about wet my pants. The dose was for a 170 lb adult....not a 70 lb child. Someone put the weight in pounds in the computer and the pharmacy thought it was Kilos. This child got the toxic antibiotic for 3 days. Thankfully there was no ill effect. The mistake was shared by all involved and all who hang the drug. It was a systems error and from that day forward in the computer, both kg and lb was displayed .........but you need to be very careful.

    I always emphasize a few rules. If someone is very small....so should the dose be. When giving meds to infants, weigh them again to be sure OR/AND look at the kiddo. The rule is kilograms and if you have an infant that is 6 kilos they should be the size of a thanksgiving turkey (12 lbs) not an oven roaster that is 3 kilos or six lbs. Seem crass but it works if you have no children of your own.

    I had a policy in the ED that weight needed to be verified by 2 methods scale and Broselow tape or scale twice and ask the parents and verified with another nurse/medic. So, the baby is weighed in triage. She puts 6.1 on the chart. You do the usual febrile infant w/u and are going to give meds. You get a quick Broselow measurement and ask the MOM...What does baby weigh at last check up? OR You tell MOM...follow me I want to double check babies weight before I give the medicine, to be safe. I've never had a Mom object.

    YOU convert that to KG yourself, do your calculation and have your math checked. for those who don't know....The Broselow tape, which uses color-coding to approximate a weight based on the child's length, is widely used during pediatric emergencies to quickly estimate drug doses and the correct size of resuscitation equipment.

    I'll make a bet you will not let this happen again and it will make you a better nurse. It's not the mistake but what you do now that makes the difference. Now beat yourself up for today. Then take a deep, breath hug yourself, make yourself a promise that this will never happen to you again.

    Now forgive yourself.......it's ok. For all that we try we aren't perfect even if we try.
  14. by   wooh
    LOL at the turkey/chicken comparisons!hehe!