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!
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!