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?!
My pharm teacher was a a career nurse and assured us that we will all make a med error. She said it's what we do about it that defines us. You sound like a good nurse. Chin up and carry on!!
Specializes in Gerontology, Med surg, Home Health.
Making med errors has nothing to do with where one works. Three of the four times I was in the hospital as a patient, med errors were made by the nurse who only had 4 other patients.
Med errors are made because we are human. We've all made them and as long as humans continue to hand out meds, mistakes will be made. All we can do is take our time, remember the 5 rights, and hope that if we do make a mistake, no one gets hurt.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
everyone makes mistakes. everyone. what matters is what you do after you've made the mistake, and you did everything right. so try to give yourself a break. when you talk to your boss, you'll tell her how bad you feel, that you know you screwed up, that you'll be far more careful in the future. that's what she wants to hear. and then you forgive yourself.
Well, I guess you won't make that same mistake again!
Relax, this is something we all go through. My first med error? During my pediatrics nursing preceptorship at the end of my last semester. Gave Flagyl to the wrong baby PO (had 2 babies, same age, same diagnosis, looked the same, everything). Had to tell my preceptor, the doctor (who was NOT happy), and had to have a meeting with the director of the nursing program. Because I was up front and honest, I was able to graduate. I was so happy I cried. At the end of the meeting with the head of the nursing school she said "I'll bet you'll never do that again. But don't worry, hon...we all need a little Flagyl sometimes." Ever since I have been completely anal about the MAR and the identifiers, 5 rights, 3 checks, all of it. It has made me a better nurse and this will do the same for you. Yes, I still make mistakes, but they are different mistakes and each time I learn how not to repeat them.
When you talk to your ADON, they want to know that you learned from your mistake and how you can make sure it wont happen again.
My last 2 med errors were I forgot to give an anti seizure med, didn't catch it untill we were doing the narc count at the end of the shift. I gave the med 2 hours late and had to write up the error report, I stated that I would double check my MAR after each med pass.
My second error was a weight based ipubrofen. Child was weighed during my shift, I used that weight to calculate the dose. It seemed a little high. Later on in the shift, I was speaking with the nurse who normally works with the child, and I told her the weight that I had, she had known the childs weight from before and knew that my weight was too much.
Re weighed the child and yup, the weight was off by 9 kg, the med was 10mg per kg so I overdosed the child.
Again I had to do the med error write up and in my form I stated that I needed to check the previous weight with the knew weight to look for any major descripancies.
I had only be at this job for 4 months and I was so worried about what my manager would say. But my manager was fine, no harm came to either of my kids, I was honest about my mistakes and my manager said she apprciated that I came up with a plan to make sure I didn't make the same mistake again.
I apologize for my post being so long, I just had to get this off my chest and look for some advice!
You are human and will make mistakes. You gave a prescribed med to the right patient just not at the right time. Be happy you reported it and took responsibility. That shows character. Also be glad you did not give the wrong meds to the wrong patient.
Oh honey, bless your heart. You did what you were told to do by the senior nurse and the doctor. I would just document everything and how it played out for yourself and know all nurses make med errors, it is just a matter of time. And the ones that say they don't are the ones to watch out for!!
I remember my last qtr of my LPN yr I gave a protein drink before lunch rather than after lunch. I immediately told my instructor. That day a few students made some med errors or almost med errors. Our instructor said that as ppl get more comfortable they tend to make errors. I keep that in my mind at all times. I'm anal about checking things. When I was a brand new nurse I instructed my CNAs to leave notes if I was in the middle of a med pass and I would look at the note as soon as I finished up a resident.
i know it is a horrible feeling even with minor mistakes, but i promise you if you asked any nurse if they remember their first med error, they can describe it in full detail... we remember those feelings and relate them to what happened and it will stick with you, and in the larger picture, make you more aware and cautious in the future. i also got very upset with my first error and am now much more meticulous. especially with counting controlled meds (I work on a detox floor so we would literally have hundreds of them for protocols) and now every time the drawer opens, I recount them, even if i had JUST counted them on the pull before.
I am still a pretty new nurse, but before I made that mistake, i would rush if i was running a little late to try to get patients who are already "not happy campers", understandably, due to withdrawal become even more irritated when they don't get their meds on the hour/minute/second... but i would rather be safe and 15 minutes late than fly through it and harm someone. that being said, i better add on detox, i do assess first thing and if i have a patient with unstable vitals or at risk for DTs, on seizure precautions, etc. i usually pull their meds first and give them before pulling on patients who are stable and well through or finished/almost finished detoxing.
but like everyone has said, the main thing is you learned from it. you reacted properly... notified your supervisor... and most importantly, made sure the patient was safe! don't beat yourself up =) you sound like a VERY caring nurse- there are some nurses, sadly, who would just "fix" the documentation and pretend nothing ever happened.
just relax, know you responded appropriately, and learn from this. i give you a pat on the back for handling it so well! you sound like you are and will only get better at being an attentive, compassionate, caaring nurse.
It has been about a month since my post here and I just wanted to update everyone. When I went in the Monday following my error my ADON approached me and asked about the error asked if I knew how it happened, how to prevent it from happening again, and was going to let it go lol I was in tears and asked her if I could talk to her in her office. I told her how I was making myself sick over my error and she assured me that it was human, that it was taken care of corectly and that I was silly to make myself sick over it. LOL I am so relieved! I have since then tried to become more organized with my meds, really sticking to one system when checking my rights and rechecking any time I get interupted.
I just wanted to thank you all for your responses...you all helped me thru what was a very scary experience for me! You have no idea the impact your responses had! Again, thank you!
My resident was supposed to get scheduled lyrica at 9am and scheduled morphine at 2pm. 
SkiMama
141 Posts
My pharm teacher was a a career nurse and assured us that we will all make a med error. She said it's what we do about it that defines us. You sound like a good nurse. Chin up and carry on!!