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!
Thanks for sharing this. This reminds me of something I learned in a previous profession. I used to be a Park Warden, in Provincial Parks. We were badged officers and could arrest people, under specific legislations. When I learned how to arrest and search individuals we had the rule hammered into us that anytime we passed on that person onto the next officer, they would do a full search, and so on and so on. I asked why would the next person search them if we already did it, and I was told "because they might have missed something, don't always trust they did a perfect job". That's always stuck with me, and reminds me of this story. Good advice to remember as a Nurse, I guess.
It would be nice to have a resonable amount of patients per nurse so we could all do total care for our patients. I think that there would be a lot fewer errors in general if this was the case. Our assessments would be better, vital signs would be accurate, and med pass would go much smoother (IMO). Alas at the end of the day $$$ rules all... forget the common sense factors.
It would be nice to have a resonable amount of patients per nurse so we could all do total care for our patients. I think that there would be a lot fewer errors in general if this was the case. Our assessments would be better, vital signs would be accurate, and med pass would go much smoother (IMO). Alas at the end of the day $$$ rules all... forget the common sense factors.
Yea, I totally agree! It seems to be more about the money and making sure the patient is "happy" with our service than safe with our skills.
Anyhow, if I have an abnormal vital sign given to me by a tech with a PRN med available I always recheck it myself before administering anything.
our techs arent allowed to do vitals at all because of this reason. the glucometers we have automatically put them into the computers as soon as they are taken so thats no biggie. i could see why you'd be worried:***:!!!
OP, you should be commended for your care and honesty. there are some nurses that i know who would have said "eh" or perhaps didn't even notice the BP AT ALL or worse still, let an entire day go by without any vitals being measured.
I too wish that there was a way we could just have 3:1 ratio and do all care. maybe one aide just to help answer call bells or help with max assist patients or turns.
Canucker2014
64 Posts
Thanks for sharing this. This reminds me of something I learned in a previous profession. I used to be a Park Warden, in Provincial Parks. We were badged officers and could arrest people, under specific legislations. When I learned how to arrest and search individuals we had the rule hammered into us that anytime we passed on that person onto the next officer, they would do a full search, and so on and so on. I asked why would the next person search them if we already did it, and I was told "because they might have missed something, don't always trust they did a perfect job". That's always stuck with me, and reminds me of this story. Good advice to remember as a Nurse, I guess.