7000 fatal med errors last year-where are theses nurses?

Nurses General Nursing

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hi my name is julie. i have been a nurse for 15 years and have loved almost every day. i can easily say it is my passion, however, less than a month ago, i made the first and only med error of my 15 year career. i hung a med that looked like pcn, but was not. it was a cardiac toxic drug and resulted in the almost immediate death of my beautiful pt, and the end of my life as ive known it. my spirit is broken, my ability to take the next breath, severely challenged. and the internal battle against the thoughts that are there to defeat and destroy me are constant.

i am feeling desperate to connect with anyone who has lived through this same horror. i have been trying in vain for over a week to find some way of linking up in a support group for nurses trying to get thru something like this. of the 310,000 med errors in this country last year, 7000 were fatal! where are all those nurses?!! are they all suffering alone like i am?

PLEASE, IF YOU HAVE BEEN THRU A SIMILAR SITUATION, CONTACT ME. I BELIEVE WE CAN HELP EACH OTHER SURVIVE IN A WAY OTHERS MAY NOT BE ABLE TO UNDERSTAND. i am outraged that a support network does not exist for these nurses even with documented sucides reported.

any suggestions? thank you and i am so sorry for the somber theme. julie

I am so sorry that you are having to go through something like this I will pray for you and the patients family.

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Specializes in LTC.

My thoughts and prayers are with you. I can't even begin to understand the state you are in now. I hope you are able to find the support you need and are able to work through this.

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one med error in 15 yrs is commendable.

i've made errors over the yrs, one near-serious.

my confidence was shattered for a long time, and had other nurses check my meds and dosages for a long time.

even though i had the support of my don, risk mgmt and all involved, i was petrified of another repeat.

once you can put everything in proper perspective, you'll be gentler on yourself.

sending you warm hugs and well wishes.

leslie

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Specializes in orthopaedics.

dear julie, you have gotten some wonderful words of wisdom here. i hope that this error does not stop you from continuing to be a nurse. you are obviously a compassionate person that truly feels deeply sorry for what has happened. this being said you need to continue you with your compassion and care for others. you did not do this to intentionally harm the patient it was an error that any one of us are capeable of. i pray for you to find peace within yourself and the courage to continue your career. :redbeathe

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Specializes in RN, LNC, Owner of Staffing Agency.

Julie,

A mistake was made, there is not need for continued shame and guilt. Everything is going to work out with time. Be kind to yourself, forgive yourself and with each day that goes by, find something to be thankful for. Things could have been worse...that's the first thing to be thankful for today.

Prayers your way--------

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I can not imagine the heart ache you must feel Julie. You have been a nurse for 15 years, and have had 15 years to touch peoples lives, improve the quality of their lives, and extend the years they can spend with their loved ones. And certainly this has been your intention for 15 years, and was your intention when you went to work that day.

I believe we are ultimately judged by our intentions and our actions rather than our mistakes, or our unintended actions. Your 15 years of service has done more in many senses then 5 minutes of one singular mistake.

No single mistake can negate all the positive you have done. Godspeed in finding the comfort and support you need at this moment. There will be more moments, and more moments for you to touch and improve upon the lives and the health of others. Your life and your career are not over.

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Specializes in Assisted Living Nurse Manager.

Hi Julie,

Have not seen any new post from you so I just wanted to let you know that I am thinking of you and sending prayers your way. I pray for your comfort and peace during this time. We are here for you if you need to talk.

nd_mom

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I too have made errors. In 15 years I have made 2 significant (sp) errors that were potentially deadly. The first actually ended up benifitting the patient. I work ED and was fighting with the internal med team to intubate and sedate a very sick septic pt, they did not want to as he was 'not an ICU candidate', I got mad and finally said "you have got to at least sedate him--he is going to fall off the bed and he is ripping his lines out." They ordered 20mg of Valium (hx of etoh abuse) I thought they meant IV, they meant IM. I gave 10mg, waited 10 min and gave the 2nd 10 mg. As the team rounded on the pt he resp arrested. The attending was not pleased, they were forced to intubate, the ICU guy was livid, but the man got appropriate care, I just got the greif.

The second was not so good for the pt. A very anxious mother and daughter team, the Mom had a picc line for chemo--they were harrassing us all day for minor stuff, and I cannot even remember why she was there, "she is near someone coughing", "the sheets have a spot", "was this room cleaned properly", etc..... Mom finally got her get out of the ED card and I went to D/C her picc and flush her line so she could go.

I grabbed the heparin and a 10cc syringe and ran in so I could get rid of these pains in the )&*&(. As I slammed the syringe full of fluid in, I realized what I had just done---flushed the line with 10cc of 10,000u/ml of heparin. I was freaked.

The doc on was surpizingly wonderful--he has a reputation of not caring about anyone but himself, but let me tell you, he sure went to bat for me. He called hemetology to find out if we should give the antidote for heparin (that my brain cells are blanking on right now cause we never use it) and they said no, just moniter as there are too many side effects. I went to the Mom and Daughter team and explained everything and apologized. Lots of tears, and the daughter went nuts--unitl she realized Mom was now going to be admitted for observation. I followed the pt, and her clotting times did not come down for over 5 days--they should have been down the next day!!! I lived on egg shells!!

Mistakes happen, we are busy ----WE ARE HUMAN!!!!!!!!!!!!! Is your work supporting you, are your collgues and manager behind you? What about the docs? Is there an internal support phone line?

You are right we need a support group--if either of those pts died because of me I would be freaked out, but looking back on my 2 near misses I realize there are system errors that also occured and my shoulders need not be that broad. NOR DO YOURS. You are a good nurse, and as everyone else has said--think of the good you have done.

Could you start a thread "What is you worst med error?" some version of a support group? it is all annonymous right? Are we not supposed to be learning rather then blaming?

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My heart goes out to you. I could just have easily made the same error, as could many other nurses. I've had my share of med errors too. We work in a fast food pace, but unfortunately if we make an error it can have serious consequences - sometimes, I feel like we're set up to fail in such a chaotic environment.

Often a mistake cannot be attributed to any one person - it's often a system of errors, and since the poor nurse is the last checkpoint to the patient, we take the flack.

If you've only had one error in 15 years, then you're amazing. Don't beat yourself up about it. You obviously didn't mean to do it, as you've already dedicated your life to helping others, and you've done just that for probably thousands of patients.

Best of luck to you. Try to remember the number of those you've helped. You'll get through this.

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Specializes in Flight, ER, Transport, ICU/Critical Care.

I will hold you in my prayers. I can not imagine what you are going through and the range of emotions that you must be feeling. I hope that even in the absence of support from others that have "done the exact same thing", you will find support from many others! I know that there are EAP programs and counselors that do specialize in the treatment of medical professionals. Please find someone that you can, in confidence, talk with at this tragic time.

I think we have all made a medication error at some time in our career, if we have been at this for any time. If there are some who haven't made a mistake, it is likely that they will at some point in their career. Medication errors are system failures, it is just unimaginable that you are taking the entire blame. The patient is not the sole victim here.

You are not alone. My heart just breaks for you. The exact nature of your error is less important than the end consequence and we all must recognize "but for the grace of God, go I". I recognize that I am not immune from error.

Yes, there are going to be things that must be worked through - many unpleasant and emotional. Care for yourself, surround yourself with family/friends and those whom care about you. This, although tragic, is ONE mistake. It is hard to keep perspective with your eyes full of tears, but your life depends on it. If you are feeling unsafe you must call for immediate help at once.

May God bless, protect and care for you.

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Hi Julie,

The med error that you are talking about, "went to hang pcn but it was another drug", sounds like what happened at one of the other hospitals in my town. Let me tell you, we have talked about this on our unit over and over, you are in all of out thoughts and prayers. Our heart goes out to you and we don't blame you, If I could tell you how many times I have heard fellow nurses say, "that could have been any of us". And let me tell you, there are so many factors involved in a med error, it's a system problem, I'm sure it feels like a personal one though:o. I hope you get the support you need.

Take care.

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In my graduate year as an RN, I was placed in the ICU for a rotation. After one month there, I administered potassium chloride into a burette and set the drip rate for one hour infusion. Unfortunately, when I returned to check it in 10 minutes, the entire infusion had run through, due to a malfunctioning IV roller clamp set.

This was not your fault. Speaking as a quality engineer (I am not a medical professional), it is evident to me from what you have written that unreliable equipment was to blame. I am surprised that the family did not sue the equipment manufacturer.

How would I handle this? There are plenty of commercially-available flow monitoring devices. If you set the drip rate for a one-hour infusion and the meter detects a flow rate that will result in delivery of the entire dose in ten minutes (i.e. it is running six times as fast as you set it), an alarm should sound and the flow should shut down immediately.

The person who started the thread wrote,

"i hung a med that looked like pcn, but was not. it was a cardiac toxic drug and resulted in the almost immediate death of my beautiful pt,"

All right, how did the mix-up occur? Two drugs whose packaging looks similar sound like a mistake that is waiting for a place to happen. I need more detail to understand this but I'm pretty sure that this could not have happened under any decent quality management system.

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