First Med error and plain old frustration

[newrn05]

I have been an RN since August of 2005. I bounced around a little becasue I would have to orientate on days. I am by no means a day person. My preceptors would tell me I was doing fine but then I would be asked to resign because I was not doing well enough as a new grad. I kept telling that that I needed to go right to third shift. That is how my body clock is. I am suprised I made it through nursing school.

I found a job at a hospital about 45 min from my house. Now there are three within 15 min of me but they didnt work well. I could have went back to one of them but the politics there are horrible. This new job is great. I told the NM that interviewed me that I was a slow starter and that to be honest I don't function well on days. She offered me the job on the spot and actually had to create my FT position. The only catch was I had to work 12 days for at least a month. That preceptor had to approve me for my change to nights.

The first day with my preceptor I sat down with her and told her what I thought my strenghts and weakness were and that I did not function well on days. I was completely honest except for the fact that I have ADHD and that is the biggest reason I dont do well on days. (To many distractions for me) We started slow. My previous experience as an aide and as a nurse extern was helpful. When i only had 1 or 2 or 3 pts I could help out the other nurses on the floor by passing meds and helping with things I already knew how to do. My biggest problem was the interupptions by the docs and not knowing all of them. Things were progressing well untill last week.

My First Med Error....OMG i cried for hours afterwards. THe pt was found to have PE...lots of them as well as clots in his legs and else where in his body. He was on heprin drip and was on complete BR. I was so busy that day because I had went from 4 pts to 6 that week. I had a brain fart and hung levaquin with his heprin line. A few hours later we got his aPTT back and according to the protocol we had to bolus him 3500 units and increase his heprin by 2. So we went to his room, precpetor with me and she said OMG did you hang the levaquin with the heprin. I jsut looked at her and said OMG about 5 times. We checked the line and it was clear and flowing...no crystalization. I flushed the line and then pushed the bolus....it immediatly crystalized. i pulled the IV line and got two more started. One for heprin and the other for the other IV meds. He was fine....but I could have killed him. I wrote up my paperwork on the medication error and asked my preceptor where I put it. She said she was proud of me because I immediatly took responsiblity for my error. The educator who works closely with us told me she was aware of the error but despite that my preceptor felt that I was safe and could move on to thirds.

NOw I take an extra few minutes at the start of each shift to look at all IV meds that the pt had ordered and look them up in the pysis system for compatabilty. I jot down my notes on my "brains" that way I dont make that mistake again. Each time I have a pt with heprin running I automaticlly circle it in red and put virgin next to it as a reminder.

Previous employers would ahve fired me for a med error that soon. Each and every person told me that we are all human and we will make mistakes the important thing is that the pt was not harmed and that I learned ways to not allow that type of mistake again.

I am so glad that I found this job at this hospital..They are very understanding and more then willing to teach and to help me grow.

Just thought I would share my troubles.

Can anyone else suggest ways to prevent med errors.

Dawn

[Tony35NYC]

I think its great that you acknowledged your mistake and immediately took action to protect the patient. Your colleagues are correct that human error is always a possibility and we can never be too careful. I always check for compatibility issues when I have a patient on multiple drips. Even if the nurse from the previous shift had ran them together with no problems I don't assume anything. Its a habit I got into after being chewed-out (BIG TIME) by a clinical instructor who once deliberately stood by and watch me almost make a similar mistake when I was a student.

If you're taking care of a lot of patients at the same time and you find yourself running too fast or becoming overwhelmed, when it comes to meds make yourself stop and go over everything again before you give it. I know some people will say this is not good time management but I believe in 'better safe than sorry'.

[LauraLou]

I'm a new grad in L&D and I almost made a med error a couple of weeks ago. The pt's placenta was out, so I went to bolus her with pitocin. She had numerous bags hanging and I started to bolus her with magnesium sulfate by mistake! Luckily my preceptor was watching me and caught the error. A bolus of mag sulfate could have done a lot of damage.

Once I stopped shaking, I worked out a plan to make sure I never do something like that again. I now label all my lines with the name of the drug. We are all human and it is easy to make a mistake when you are stressed or tired. For me, making, or almost making, a mistake was a big wake-up call that I need to be very careful and find ways to help prevent errors from happening.

[traumaRUs, MSN, APRN]

Hi risk medications, heparin, digoxin IV, insulin, most pedi meds should be a double check with another RN. This is a JCAHO-mandated procedure to reduce med errors. Is this in place at this clinical site?

[jonear2, RN]

my med error was an identification error. It was with insulin...see if you can catch how it happened....

I read the blood sugar from the pts flowsheet, checked the sliding scale for the insulin type and dose. Verified all of this through my preceptor, dose checked, drawn up correctly, correct type. Took MAR in the room, verified armband etc. Administered the insulin.

Wham! wrong pt. Did you guess how. Based my insulin dose on the wrong pts blood sugar. See, the clip boards that hold the flowsheet have a plastic sheet over the front to protect HIPPA and when i lifted it I failed to pull the flowsheet down far enough to see the pt label on the top. I learned that you cant assume A bed's flow sheet will be on A bed's clipboard. Another check that must be done. The pt was fine her lunch came, and i gave her extra juice, informed the preceptor and the manager immediately as well as the doc. But i felt so defeated because i thought i had done every possible check. but you really cnt be too careful. I cried and cried. I still wake up in a cold sweat at night 5 days later. And the next day i was so shakey passing meds. I am petrified. i could have killed her.

but it is a lesson i will NEVER forget.

[truern]

jonear, I can sooooo see that happening. I can't tell you the times I've started to chart on the wrong flowsheet because the clipboard had the wrong laminated coversheet.

Thank goodness no harm came to your patient, and it was a lesson well-learned.