First med error

merrywhiterose · Aug 29, 2012

We are not allowed to use our phones at work. Also, most med errors here are due to changes in orders that are easy to miss.

acbrn88 · Aug 29, 2012

Well I almost hate to say this but its good to know that others have had horrible experiences in LTC as well. I got a job at a LTC facility a few months after I got my license, jobs were few and far between for a nurse with no experience. I worked there for six months (And never have I EVER left a job so soon) but it was the most miserable place to work on the PLANET. Ok, well maybe not but you get the picture. A lady that I have come to see as my mentor (She works two jobs and I got hired on at the hospital she works at) told me to GET OUT. No ifs, ands or buts about it. I finally listened. They make new grads (having been out of school six months or so) managers over whole units and give them way to much to handle as a new grad. Shane 505 was absolutely right in everything he said. You have way too many people to pass meds to and not enough time and its easy to make med errors. I made my first there, as well.

In my LTC facility we still used paper MARs, and at the end/beginning of each month they have to be 'checked off.' We got our assignments and I understood how it worked, but what I failed to realize was that after the 'new mars' were printed and started to be checked off, any new order written had to be put on both sets of MARs. I signed off a Coumadin order for someone (and generally INR's were done once a week unless the range was totally crazy) and I put it on the current MAR but not the new one. And after the beginning of the new month the pt didn't get coumadin for three days until someone caught it who remember the pt getting coumadin previously. Someone else was supposed to check behind me and they didn't catch it either but the point is I didn't do what I was supposed to (which I still believe to be my fault even though I was never shown or taught how to do this correctly, learned by trail and error as you can see). BIG med error. I worked a rehab hall so some of my pts ask what they are taking, etc, but this pt was also mentally retarded and couldn't ask what he was taking he just trusted I was doing my job, which made me SICK. He had filters in his legs, so I didn't cause any harm, and it was my mentor on duty when it was found out. She took me for a walk outside the building and explained things to me. I was so upset I threw up. So I feel your pain, dear. Don't be discouraged. Its like anything else you just have to pick yourself up and keep going. Things were fine, my pt was ok. Since then I have accidently done other things too.

My point is this, like others have said, be glad you didn't hurt anyone, there are worse (MUCH WORSE) errors, and EVERY NURSE makes errors. We are human too. I work at a teaching hospital now and lots of errors are made. But there are many many checks in place to help nurses out to hopefully keep us from making mistakes. We have to scan meds and scan the pt and two nurses IDs are used to give insulin, stuff like that. I received adequate orientation at the hospital though, at the LTC facility I received one week of following a nurse around who wouldn't let me do anything. I was scared for my license, so I started looking elsewhere for a job. I had my new job lined up and then turned in a notice to my old job. (We were being forced to work 5 and 6 12 hr shifts per week due to short staffing, I had 40+ pts on my own at night for night shift, I also had times where there was no nurse to relieve me so I just had to keep passing medicine. Let me say, after 16 hrs you are ready to GO!) When I told the DON I was turning in my notice they told me not to work it out because they didn't trust me. *crazy* Anyway, not all facilities are like that, I am sure, but I LOVE LOVE LOVE my job now. I work a normal rotation schedule, 3 and 4 12's a week, straight nights, I always have relief, I learn new things every day, I have co-workers that help and managers that ROCK! It has its rough days but I feel like I am learning and actually getting to be a nurse now. So there is light at the end of the tunnel. Keep on doing your thing, you are a great nurse, don't feel like you aren't!!=)

Pjking227 · Aug 29, 2012

I got my first med error today, and while the patient was ok. I'm terrified. I'm worried for when the DON sees it. I had talk a week ago for a charting error and just that and this and I'm terrified for what's going to happen.I just don't know what to do. I mean I'll own up to what I did and hope it doesn't affect me too badly. But at the same time it just worries me so much.

You are human, you will make mistakes. What kind of error can you make with charting? This place sounds like they are practicing nursing from 40 years ago. A mistake is a learning experience. And I have worked at places where you get written up and we all learned to cover our tracks. Now most places use these mistakes as learning experiences to improve passing medications. If they are willing to lose nurses over being human, then you need to find somewhere else to work. Chin up, you will survive this. You can turn in your own "write up" before anyone can find out and then tell the DON how it happened and how to correct it. That is just a suggestion. But, I would be looking for another place to work.

leanjess · Aug 30, 2012

It seems all y'all are more worried about yourselves and not about the residents who could suffer because you made a mistake.Not all SNfs are horrible. We give new nurses at least a month of orientation...some more than that. Is it the fault of the facility that new nurses didn't learn enough in school to be safe? I think not.

Wow! One month of orientation? Really?! I got just 5 days of orientation, and they put me up alone on the med cart. Plus I had a fall while on my med pass..it was the WORST day of my life. Looking at quitting and looking for jobs in the hospitals. I'm a new nurse too, I graduated in May and this is my very first nursing job. This week is my 2nd week there and I can say I'm not having the best experience.

BrandonLPN, LPN · Aug 30, 2012

Med errors need to be viewed as an opportunity for education, not punitive action. Instead of a "3 strike" policy maybe after three med errors you have to have a conference with the DON and determine why the errors are happening. Maybe how orders are noted needs to be changed. Maybe the med cart is confusing. Maybe things are getting missed in change over.

CountyRat · Aug 30, 2012

The problem with the three strikes approach is that it does not address the problem. Punitive measures (which 3 strikes is) are appropriate when someone has knowingly done wrong. If a nurse knowingly gives the wrong med, she should not get any more “strikes.” She should be discharged at once and reported to the board of nursing for punitive action. However, that behavior is intentional, medication errors are unintentional, and the approach that works for willful wrongdoing will not prevent unintentional errors.

When someone commits an error, the most rational and effective approach is to set aside our natural desire to label someone as the villain, and calmly analyze the steps that lead to the error. In almost every case, not one but several process failures will be identified. Now, armed with the facts, we can talk about how to change the process in ways that reduce the likelihood of similar errors in the future. This approach can help us improve patient care. The punitive approach may satisfy our primal desire for vengeance, but it will not change the things that caused the problem, so patients will not be safer, and isn’t patient safety (as opposed to vengeance) the goal?

CountyRat · Aug 30, 2012

When I told the DON I was turning in my notice they told me not to work it out because they didn't trust me. *crazy*

That is so, darned (not the word that I am thinking) typical of how nurses are managed. You were being punished lake a naugfhty little girl for making what was actually a very mature and reasonable decision. I love patient care, but I hate hospitals, :madface: and acbrn88's post reminds me why.

morte, LPN, LVN · Aug 30, 2012

If the ASA was not to be given, it should have been removed from the MAR. "holding" a med does not meet JC guidelines. They must be d/cd and restarted. good luck

NottaSpringChik, BSN, RN · Sep 1, 2012

Which bring up exactly why there should not be punitive measures in place for making med errors. Each med error is an opportunity to examine the processes and circumstances that contributed to the error. How could the error have been prevented? What process or support could be implemented or revised to prevent the error? Yes, the nurse was the final link in the chain, but many times there are improvements that can support the nurse and others to prevent or detect errors before they affect the patient. That three strikes policy is very outdated.

Isitpossible, LPN, LVN · Sep 1, 2012

I made a med error with coumadin - I did not give the med. I realized my error, and went to the DON... she looked at me said, "okay so what do you want, me to beat you up more than you already have?" I had tears in my eyes... she said your a new nurse, and wont be the first or last nurse to make an error. She was more concerned that I LEARN from my mistake and not make that same mistake again. She then told me to contact the physician, and family members and write up an incident review. End of story.

annlewis · Sep 4, 2012

It seems all y'all are more worried about yourselves and not about the residents who could suffer because you made a mistake.Not all SNfs are horrible. We give new nurses at least a month of orientation...some more than that. Is it the fault of the facility that new nurses didn't learn enough in school to be safe? I think not.

Wow you sure are harsh, most nurses are trying their best to be safe, but remember, we are human, things happen.

CapeCodMermaid, RN · Sep 4, 2012

I don't think it was harsh at all. I am well aware that everyone makes mistakes and sometimes it is the fault of the system. But the posters seemed to be more concerned about how the med error was going to effect THEM. It's not about them....it's about the resident.