First Med error??

[NightNurseRN13]

PDN nurse here. Got to work and see a note saying New prn order for ophthalmic solution atropine for oral secretions, TID. I look at the Mar and see it was last given at 0800 and it's now 2300 so I find the bottle and read the instructions and it's to instill one drop in each eye TID, so I did. Later I was having a conversation about how it isn't seeming to work and the other nurse agreed with me that it doesn't work. Somehow it came up that I gave it in the eye and the other nurse said it was supposed to be sub-lingual. I showed her the note and the bottle and she found the box where it says it's supposed to be under the tongue.

I should have looked for the box and the pharmacists printed instructions and I should have payed more attention to the dates of what "new order meant".

I'm pretty sure this isn't a huge issue, but It's my first error and just wanting feedback.

[Luckyyou, BSN, RN]

I did the same thing in my first nursing job! The MAR only stated that it was eye drops, so I just dropped them in there. I didn't get in trouble, people just laughed. Now we both know the right way.

[kbrn2002, ADN, RN]

Don't feel too bad. The first time I was confronted with an atropine order I questioned it too...why the heck would you give eye drops sublingually?? Turns out it's a common order for our Hospice residents, who would have guessed? Take it as a lesson learned so the next time you see a med order that seems illogical [like eye drops given orally] you will stop and question it.

[BSNbeauty, BSN, RN]

No worries. Take it as a lesson learned. When I worked in ICU and had an actively dying pt. I suggested to the intensavists atropine sublingual. They looked puzzled but they ended up thanking me laterm I came from LTC where we often used atropine drops to help dry up secretions. So dont worry. No harm was donem

[mystcnurse, MSN, APRN, NP]

The most important thing is that you made an error, and then reported it. Most medication errors are never known, unless they involve narcotics. But you can easily KILL someone by giving them the wrong dose of say, a beta-blocker. That is why the three checks are so important. And if something doesn't make sense, question it. Nurses are responsible over everyone else, for what they give a patient. There are so many avenues for mistakes to be made, nurses are clearly the patient's most important line of defense! And sharing errors can keep others from making the same mistakes. Nobody is perfect. :)

[mluvsgnc]

"And sharing errors can keep others from making the same mistakes."

This! Thank you for sharing- now I know about this med in case I ever come across it (from one PDN nurse to another)

[wanderlust99]

I just saw that order for the first time in 9 years in my current ICU on a dying patient a couple of weeks ago! I was stumped. What do I do?? An eye drop that goes under the tongue? I didn't get it either!!

[applewhitern, BSN, RN]

That is a common order in my neck of the woods; we use it on our dying/hospice patients. Please don't assume "it doesn't work" just because a co-worker said it doesn't. Actually, it only works to reduce production of secretions; it doesn't dry up secretions that are already there, so you may need to orally suction the patient before initiating the drops. It works better on salivary secretions, rather than bronchial secretions. If your co-worker claims "it doesn't work" it makes me wonder if the drops are being used correctly.

[Racer15, BSN, RN]

The only reason I know this is because I helped care for my grandfather on hospice last year. I had never come across similar orders in the ER and would have been confused otherwise.

[Girlafraid13]

We are human and all make mistakes. During my clinical rotation I drew up 40 units of insulin instead of 4 units. Glad I was a student with a teacher there. How I mistook 40 vs 4 is beyond me and could have been deadly.