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Discussion

First med error, freaking out!

Help! When I got onto shift yesterday my kid had TPN and lipids running. During report, the day shift RN and I did our double check for the hanging medication and everything looked perfect. He was getting TPN at 28ml/hr. I didn't touch the TPN or lipids all night. I drew his labs around 5am and paused the TPN and lipids to access his line but otherwise didn't do anything else to the pump. When I gave handoff report in the morning, the day shift RN saw that his TPN was running at 29ml/hr instead of 28!

I know it's only a l difference but I'm kinda freaked out because it's my first medication error. The TPN and lipids were already running when I got onto shift but I can't figure out where in the night the rate got changed since I didn't do any IV meds or access his line at all except for labs!

I don't know if he got an extra 2ml of TPN between 0500-0700 when the day shift Rn caught it or if it was running at the wrong rate all night, so he got 12ml extra of TPN.

I also didn't even think to page the team about it cause we were in the middle of handoff and the day shift RN brushed it off so quickly.

Im going to talk to my charge about it tonight and probably fill out a med error report. This is my first med error ever (even though I didn't hang it, I didn't catch the wrong rate!) and I'm kinda freaking out. Obviously I'm a new nurse, this is my 6th month. Help please!

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    I'm sorry... how did this happen? You checked it with the other nurse and it was at 28 and you said you didn't touch it. The pump doesn't change itself, so somehow someone typed in the 29. Either you or the other nurse.

    You need to do a RCA about this and find out where the error lied.

    Be up front with your manager about it. Own it if you did it.

    An aide got a sugar for me and told me the glucose was 185. So I wrote it down and medicated the patient for the 185, which was 3 units. The glucometers don't update right away, so once the result came into the computer I saw the patient actually had 158 for their glucose... that the aide accidentally switched the two numbers in her head when she reported the value to me.

    Well I had already given the insulin!

    I told my manager and she totally understood... reminded me to look at the result myself in the future. Monitor for signs of hypoglycemia. But 3 units for a 185 would be fine. At 158 he would have gotten 1 unit anyway.

    Hopefully, if you own the mistake and report it to your manager, then he or she will see your transparency and honesty, which is more important than anything else. They generally want nurses that will recognize mistakes and own them, vs hiding them, which will cause more issues in the long run. Never hide a mistake.

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