First Med Error Blues...

[cyb3rRN, ASN, RN]

Hi all. I have been a member for a while and have come here to research things and such. I recently got my first RN job in the end of October in a ltc facility. I had 2 weeks of training and have been on my own for about a month and a half.

Yesterday I made my first med error...involving narcotics of coorifice! My resident was supposed to get scheduled lyrica at 9am and scheduled morphine at 2pm.

So, the coorifice of my day (and trust me I am not trying to make excuses, I know that I failed to work safely) as I know many of your days are probably similar...I had just started antibiotics the day prior for a sinus infection, touch of bronchitis, and an ear infection I wanted to call off more than anything, but just couldn't bring myself to since I am the new nurse and that would look horrible being there less than 2 months and calling off, I wanted to look dependable. I even told one of the other nurses that I felt "off" and "foggy" when we clocked in in the morning. Plus it was a weekend day which meant there are only 3 scheduled nurses so a call off would most likely mean a manager would have to come in and cover the shift. It was a usual crazy busy day... 20 residents to care for with 5 million meds, the aides coming and reporting things, one resident not doing well (will pass away any time now), family coming and going wanting updates, so on and so forth.

So, during my 9am med pass I go to get resident X's meds. I check all my rights, someone comes up and asks me something (I can't even remember who or what it was now!) and I go on about my business. I take the medications in and give them to the resident. When pouring them into her hand I realize that they just didn't seem right to me. I go back out to my MAR and then it hit me!!! I gave her her scheduled morphine instead of her lyrica. Both are in our narc lock boxes and I'm just so used to giving her both it didn't send up any red flag for me. My legs immediately turned to jello!! I felt like all the blood had drained from my body and the room was spinning! I took a second to recheck my steps to make sure that I really did mess up and confirmed it when I looked in the narc book, I had signed the morphine out at 11am (I was super behind and always save this resident for last)

So, I immediately ran to the senior nurse on duty to ask what to do. At this point I am already crying and having a mini panic attack. I was sick, tired, not clear headed at all, new, already overwhelmed on a normal day, and this just sent me over the edge...I couldn't keep it together! She instructed me on what I needed to do. First she checked out the error I made and said she really though it wouldn't harm the resident. I checked on her and then called the doctor. I don't know if this on call doctor is just normally nice or he could tell that I had been crying, but he was extremely nice and laughed after I told him and just said "Well, give the lyrica at 2pm and hold the morphine" I filled out my error report and put it in an envelope in my ADON's mailbox. (The senior RN told me that the supervisors don't want called for simple med errors on the weekends) I told the resident the error that I made (tried not to make it sound like a big deal because I knew I would break down in tears if I let on to the severity) and told her that I had called the doctor and what he said to do. Her response was "Thats fine with me." and took her afternoon meds and I went on relieved that I had told her, breaking out into tears throughout the rest of the day.

I cried almost all the way home, cried on my way to work this morning and had so many thoughts running through my head!! I wanted to quit! To work at McDonald's and not have this kind of responsibility! I wanted to crawl into a hole and hide! Should I have had more training? HOW on EARTH did I miss the time when I was checking things so closely?! (I thought) Should I quit nursing? Should I switch to a slower paced shift? Ughhhh!

So, here I am, the day after still feeling SO extremely incompetent! I was just beginning to feel a tiny glimmer of some confidence and then BAM!!! I mess up big. This just has me doubting myself unbelievably! I'm ashamed, scared, embarrassed, and so very remorseful, I could go on and on...

I still still have yet to talk to my ADON, she will be there tomorrow and I really can't wait to talk to her. I just want to get it over with! I'm still terrified to speak to her not to mention all the embarrassment and shame I feel! How do explain something I don't even understand how it happened? I was just in a fog, I just need to be more careful. What will she say? What happens after that? Is the error keep on my record? Does the BON hear about it?

I'm just looking for some support, comfort, or some direction in dealing with this. I have read a lot of the posts on errors and I keep trying to talk myself into feeling better..."everyone makes mistakes" "we're all human" but it just isn't working! Maybe once I talk to my ADON. I just don't know! I just can't shake this! Is this normal?!

[cyb3rRN, ASN, RN]

I apologize for my post being so long, I just had to get this off my chest and look for some advice!

[MomRN0913]

Your human. Humans make mistakes. Odds are pretty good you will probably make more. So, relax, and be thankful nothing bad happened.

[wearingmanyhats, RN]

take a big breath...

there is not a nurse alive, that hasn't made some sort of med error in their career.

You reported it... that is the most important thing... accepting responsibility!!!

We do get interupted so many times giving meds... and it's hard not to get mixed up and out of sorts... take your time, double and triple check before giving them.

Sending good thoughts your way...

[Horsebytes]

You have learned a lesson and fortunately this didn't cause a death like another medication error could have. You can't do anything about the past... it is over - but you can use this experience to go forward and not let a mistake like this happen again.

[LobotRN, BSN, RN]

Hey cyb3RN. You didn't mess up horribly. Wrong med time/combo with no untoward effect on the resident? Of course you don't want it to happen again, and likely you will not because this made quite a lasting impression on you. That said, put this down and let it go. From what I read in your post, no one you contacted when you realized the mistake (good job btw!) batted an eye at this. I think the gist was "document, monitor, move on." Perhaps you should take a cue from their responses? Realize, too, that the strength of your reaction may be a little out of proportion with the situation. On that note, in these situations it is best to appear as someone who takes ownership rather than someone who needs an emotional bailout. Sure, you might get written up, but take it as a learning opportunity, and don't fall apart over this. I think rn/writer's article on the home page today may really give you some balance on this..... ♥

[Sparrowhawk]

Hon, it's ok...everyone at some point makes at least one error of some sort. Sit down, have anice glass of wine (or something else) relax..it'll be ok. Really, it wasnt that horrible of amed error, you've learned now..slow down when you feel sick and double check after you get interuppted *hugs* It'll be ok...Put in a movie your fave actor is in, drink some wine, have some chocolate, spend some cuddle time with your partner if you have one...The GOOD thing is you did the RIGHT thing, hon, you were upfront, honest and didn't try to cover it up...

[cyb3rRN, ASN, RN]

Thank you all for your responses! I think I just need some time. I know you all know where I am coming from when I say that I have worked SO hard to get here and then to mess up in such a short amount of time is just heart breaking! I'm so glad you all are out there in cyber land to support me as I am not yet close to many of my coworkers yet to be able to vent like this! I appreciate it so much that you take time to read my post and respond!

LoBot, that article hit the nail on the head! It couldn't be more perfect! Thank you so much for sharing! I think I need someone elses persective...mine is out of order right now. lol

[PumpkinEater, MSN]

When you think of the thousands of times we pass meds it's just not possible NOT to goof from time to time (especially when you consider the pressure we're under to move fast). As you gain experience you'll begin to recognize circumstances when errors are more likely to occur.

In fact, research into the psychology of performance often shows that people who are more up front about when they make a mistake (in whatever capacity) actually know their limitations more intimately and are, in fact, more competent. That's why I'm so leery of nurses who come to these forums proclaiming they've made their "first" med error after years on the floor. Yeah right!

[fiveofpeep]

That was a minor error and the patient wasn't harmed. Learn from your mistakes and move on.

[carolmaccas66, BSN, RN]

I can't read all these responses as I have to go out.

This is why I refuse to work LTC in places with a 60-100 or more residents. It is too busy & there is not enough time to do anything.

It won't do her any harm, don worry re it. U just gaver her drug earlier & you signed for it a bit earlier that is all.

I hate LTC & will never go back there, hear and see too many tragic stories & people making too many med errors.

[VinnieG]

Its really easy to make errors in LTC. there are just so many residents and so many pills! you will be okay, everybody does it and anybody who tells you they have never made an error is either lying or they were not aware they made one!:)