First Med Error... Learned Big Lesson

[NurseyNursington]

Well, I had my first med error this last week. I'm super careful with medication, but what's so frustrating is that this error was 100% avoidable. I learned a valuable lesson about who you trust in delegation and how I'm ultimately responsible in the end.

Here's the short version of what happened:

Techs take vitals on our floor at assigned times and then give each nurse a handwritten copy of the results. One of my patient's blood pressured showed 180/90 in the copy I was given, so I gave a PRN IV blood pressure med. Ten minutes later I saw that the tech entered the patient's blood pressure as 150/90. I asked the tech about it and she said the "8" wasn't an 8, but a 5. Since the handwriting was completely legible, and it obviously wasn't a "5", I was pretty angry. The parameters for giving the IV blood pressure med was a systolic of at least 160, so by those parameters I made an error.

I let my charge nurse know, who said it wasn't that big of a deal, but I let the doctor know anyways. He also said that it was "fine" and that to check his blood pressure q1h for the next four hours just to make sure and call him with any problems. Thankfully the patient's blood pressure never dropped below 136/80, but it was still nerve wracking.

Today I learned never to trust someone else's account of vitals before giving a medication that relies on those numbers. None of the nurses on the floor take their own vitals due to our patient loads, but from now on I'd rather be safe than sorry. Big lesson learned, and I'm thankful that the patient is okay. Whew!

[NewYorkerGirl]

I understand where you're coming from. I always retake a BP myself before giving a PRN med under parameters.

I have the same issue at my hospital with glucose checks. The CNA's take them, and tell us verbally. I like to wait until they chart them before giving insulin, but sometimes they don't chart them right away. I'm always terrified they'll give me a wrong #, or get patients confused. I wish hospitals would just give us fewer patients and let us to the vitals and glucose checks ourselves.

[thenightnurse456]

This is exactly the issue I brought up in a thread where the nurse was talking about how her floor had stopped letting the techs do vitals, and how stressed the nurses were about having to now do "the techs job" as well as there own. What a horrible mentality!

Your story is exactly why nurses should be doing their own vitals! What if something had happened to the patient? Would the tech get in trouble? Or would you lose your license and job? Vitals in my opinion are part of your assessment, so why aren't the nurses' assessing? I hear some people argue "well if I got an abnormal number from the tech, I would re check it myself". Why not just do it yourself in the first place and save time?

This is a great post on your behalf as it shows you have learnt from your mistake. Thankfully no adverse event occurred. Live, learn and continue to grow as a nurse.

All the best.

[NurseyNursington]

To be honest, if I actually had the time I'd be doing my own vitals. However, when I start the night with six patients, and one hour to finish my med pass and assessments it makes it incredibly difficult. To make it worse, we only have two vitals carts for a floor of nearly 40 rooms, with only the techs being the ones having thermometers (they don't keep them with the carts). With all the RN's giving meds at the same time, it would never work without more equipment.

But yes, I learned that I'm going to be re-taking my own vitals for any meds or abnormals. I really should have been doing this from the beginning, but I think I just saw the other nurses resting on the tech's words and I shouldn't have let that be my example. All part of the learning process...

[BecomingNursey]

Always check a BP before giving a BP med. when I did work the floor before becoming an ER nurse if I was giving a BP med even as a routine medication I ALWAYS checked a BP before giving that medication whether a tech had already taken one or not. That's just nursing. If you want it done right (and it could harm your patient) better to do it yourself. Lol

I'm not telling you it's going to be easy, I'm telling you it's going to be worth it.

Author: Art Williams

[_zoubisoubisou_]

Someone above mentioned that the techs don't always chart the vitals in a timely manner. I'm still a student so I'd like to ask, is it inappropriate for you to ask or "request" the techs chart VS within a specified time? and if they don't agree?

[SassyTachyRN]

Doing glucose checks were taken from our techs in early 2010 and vitals in 2012. Rn's do it all at the hospital I just left. Techs were there for timely call light answering (customer satisfaction ratings), and bathing. Techs lost their jobs over this decrease in responsibility because we "didn't need as many of them" and RN's got no increase in pay... I will say... I did prefer getting my own vitals. You can hook the patient up to bp and pulse ox while you scan meds in, it really doesn't take much extra time to do your own vitals.

[Lev, MSN, RN, NP]

I will reiterate this point with something that just happened to me. I had a patient with uncontrolled HTN 220-40s/110-20s. She got a bunch of BP meds, nothing was touching her. She stayed in those pressures for 6-7 hours. She finally got an IMC bed but IMC didn't want to take her with that pressure and ICU refused to accept the patient (for good reason because she wasn't ICU material). Either way, the floor doc ordered labetolol 10mg. IMC said we had to wait for labetolol to work before sending patient. Was about to give labetolol with the syringe connected to her IV when I said let me check her pressure one more time. Glad I did because it was 154/115. It was in the 240s just half hour before. Called IMC and told them BP went down and took patient upstairs. I trusted my gut and learned an important lesson.

[NurseyNursington]

Doing glucose checks were taken from our techs in early 2010 and vitals in 2012. Rn's do it all at the hospital I just left. Techs were there for timely call light answering (customer satisfaction ratings), and bathing. Techs lost their jobs over this decrease in responsibility because we "didn't need as many of them" and RN's got no increase in pay... I will say... I did prefer getting my own vitals. You can hook the patient up to bp and pulse ox while you scan meds in, it really doesn't take much extra time to do your own vitals.

I definitely do my own glucose checks, even though some of the techs can take them, it's something I don't trust anyone else with. The vitals have been a problem in the past, especially since the techs hand write the results on a piece of paper and then make a copy for all the nurses. I think the practice is antiquated and can lead to errors by itself due to bad handwriting. However, even if time weren't an issue with taking my own, our lack of equipment means I'm still trusting the techs unless I re-check after they are completely done with theirs. It's frustrating, and I wish our floor was better equipped to give the nurses the ability to take our own vitals.

[JMCP]

when i was a cna, i would always notify the nurse if the bp was too high. also, then the nurse would come check it themselves.

now, i use that as best practice, if someone is telling me that bp is 180/90, you bet I'm going to check it myself before i give any meds.

[BSNRN2014]

Don't be too hard on yourself but next time remember to check the BP before giving the med.

Also, I just wanted say that it sounds like you have a very supportive team ( RN manager) which is something every new grad needs.

[NurseyNursington]

Thanks everyone. I'm trying not to beat myself up about it too much, but I did learn a great deal from the situation and how I'll handle things differently next time. And I do have a great supportive team who have always been at my side when I needed it. I definitely hit the jackpot for great co-workers as a new grad. Learned my lesson... now time to be better.