First med error!

Tweety, BSN, RN · Oct 17, 2005

No, you're not the only one to make a med error. Yes, it does make you feel like crap. We all come out of school thinking "yeah, they say sooner or later we all make a med error, but I'm the exception, I'm too careful, too smart", so when you do it feels dreadful.

The important thing is to not to minimize it (which you didn't do), own up to it (which you did) and to learn from it, which are your in the process of doing, and not beat yourself up.

Marie_LPN, RN, LPN, RN · Oct 17, 2005

No, you're not the only one to make a med error. Yes, it does make you feel like crap. We all come out of school thinking "yeah, they say sooner or later we all make a med error, but I'm the exception, I'm too careful, too smart", so when you do it feels dreadful.
The important thing is to not to minimize it (which you didn't do), own up to it (which you did) and to learn from it, which are your in the process of doing, and not beat yourself up.

:yeahthat:

JentheRN05, RN · Oct 17, 2005

I made a major med error last week. I felt horrible about it too. I had a diabetic patient (oh how I hate working with diabetics!) This patient was going to be transfered to another floor in the afternoon. I was getting morning meds ready and drew up the lantus that was ordered. Being new, I just followed what the MAR said. I forgot to look at the diabetic med sheet (these really should be combined in my eyes). Anyway - I ended up drawing up 100u of lantus and giving it to the patient (after showing it to my preceptor). Then in the afternoon when I was getting transfer papers ready, I found my mistake. My heart dropped into my stomach after I double checked it twice. I went to my preceptor and showed her, she and I went to the nurse manager. I had to tell the patient he wasn't being transferred after I called his doc and told her. I was in tears for a good hour. Anyway - once that hour was up, his doc showed up and grabbed me and said 'we need to talk!'. So I went with her to a private room, knowing full well I was going to get reamed. My preceptor snuck in after the door was closed. The doc went on to start yelling at me. I burst into tears again and tried to explain how I mixed up the MAR with the diabetic record. She saw how that could easily be done, and wasn't so hard on me after that. Even said that somehow the MAR and diabetic record should be changed so that the dose was on the MAR as well! So anyway - we closely monitored the patient all day, told him signs and symptoms and gave him ice cream. No insulin for the rest of the day and planned to ship him to the other floor the next day. I had apologized many many times to the patient for delaying his transfer. Anyway - of course we were anxiously awaiting and watching all of his blood sugars. First one was 156, second one was 144 and his morning one was 79. I lucked out, I didn't hurt the patient. I am glad I caught it when I did or someone on the night shift could've given him his evening dose of lantus and we could've bottomed him out.

Anyway - I felt like crap and still do. But I learned from it, I was anal about meds before, but now I'm ten times worse. I triple check everything, and then show ALL meds I have to draw up to my preceptor before I give them. :imbar

Town & Country · Oct 17, 2005

Being new, I just followed what the MAR said. I forgot to look at the diabetic med sheet (these really should be combined in my eyes). Anyway - I ended up drawing up 100u of lantus and giving it to the patient (after showing it to my preceptor).

Sounds like yours wasn't the only error.

If you showed the 100 units to your preceptor, why didn't she catch it?

Why was the wrong dose on the MAR?

zambezi, BSN, RN · Oct 17, 2005

Sounds like yours wasn't the only error.
If you showed the 100 units to your preceptor, why didn't she catch it?
Why was the wrong dose on the MAR?

At our hospital, if the patient is on a sliding scale, the mar states the dose of the insulin vial (at least it used to, it may have been changed to prevent mistakes like this...) so it would read: insulin regular. 1 mL=100units or something along those lines. The next line states refer to sliding scale. Because a sliding scale is used, the mar just showed the number of units in the entire (reusable) vial of insulin (100 units).

It is a systems error. I think our hospital changed the MAR- I can't remember exacetly how it is worded now.

Jen, I am sure that you will be much more careful now. A double check is always important, but make sure that the double checker looks directly at the order vs just looking at the amount of units in the syringe and repeating it back to you. Mistakes happen- in the future, remember that 100 units of most kinds of insulin is a whole lot (although I know that often lantus can be given in these higher doses so it isn't as obvious as say, 100 units of regular- still double check the high doses- against the original order if it makes you more comfortable). You learned from it and as tweety said- you didn't minimize it and you owned up to it- which are the important things. The patient was okay which is the imprtant thing- keep up the good work and things will be fine!

christvs, DNP, RN, NP · Oct 17, 2005

Yes, we have all made med errors at some point! It sounds like you did everything you could to make up for it, and checked up frequently on the pt. So that is good! :)

I've forgotten to give meds a couple of times, & then I'd be re-checking the MAR & would see I forgot to give them-so they ended up only being like 10 min late...but I still felt bad! Or this other time I was supposed to give like 10 mg of a med, & only gave 5 mg...so then when I was signing off the med, I'd notice I didn't give the whole dosage, so I ended up going back to give another 5 mg. It is totally human to make mistakes at some point!

-Christine

perfectbluebuildings, BSN, RN · Oct 17, 2005

No, you're not the only one to make a med error. Yes, it does make you feel like crap. We all come out of school thinking "yeah, they say sooner or later we all make a med error, but I'm the exception, I'm too careful, too smart", so when you do it feels dreadful.
The important thing is to not to minimize it (which you didn't do), own up to it (which you did) and to learn from it, which are your in the process of doing, and not beat yourself up.

Thanks Tweety... this really helps me out... gives me some perspective... and you are so right about thinking when I got out of nursing school, I am the exception to med errors like this... I surely thought like that!!

Thank you all for your support and reassurances. It seems like in some ways, I "got off easy"... I did not have a doctor yell at me like so many of you did... I was lucky to make the error on a pt with a very easygoing personality (though he was not so lucky!!) with a doctor who also has a very laid-back, gentle easygoing personality. I just hope he does not decide never to let me be assigned to his pts again... do you think that could happen in a case like this? Take care and thank you again, everyone, for taking time to reply. :icon_hug:

HappyNurse2005, RN · Oct 18, 2005

Well, today I completely forgot that a pt had a 2pm dose of Ancef. Good thing that at the end of each 8 hours the secretaries print up a sheet w/ everyone's uncharted meds, so I only gave it at 2:45. oops.

toadie · Oct 18, 2005

sometimes i think its amazing that more of us don't make errors. our mars have the sliding scale with the time the sugar should be checked and the diabetic flowsheets get the sliding scale written on them too. sometimes i still ask other nurses to look at my meds if they don't look right to me or if the order does not seem right.:)

LIZ_RN · Oct 18, 2005

i made my 1st med error last wednesday, & i felt so stupid bcoz it was oh so simple........ i forgot dat pennicillin IV is supposed to be given w/ D5W. good thing my patient ( a 1 yr old baby) did not have any reaction ....... i felt soo bad after that... i admitted the incident to my preceptor & she said its ok but still i feel so stupid..... i was the medication nurse that a.m... i was preparing & giving meds for 23 patients...... maybe that was the very reason i made that stupid error... :crying2:

wanda06211 · Oct 18, 2005

I am glad every thing worked out well for both you and the patient. It's not something any of us wants to happen, but these things do happen. My first med "error" was not so much a med error as it was a laspe in good judgement. Looking back on it, and knowing no one was hurt by it, i can almost laugh at it now.I REALLY do take meds seriously and the error itself wasn't funny at all, but the situation under which it happened was a little comical... you see, I was taking care of this little lady while I was a student. You know how those little old ladies love their laxatives and stool softeners. Well, this lady had an order for miralax on her MAR. While discussing the meds with my instructor before giving them we decided that since I had just spent 20 minutes cleaning this lady and her ENTIRE bed after she had just had a rather large semi formed BM maybe we should hold the laxative this morning. Well, what did I do? I marched right in there and gave her all her scheduled meds. ALL of them---including the miralax. I felt so horrible. I went straight to my instructor and told him what I had done. He was great about it and went into the room with me to tell her about it. She was good about it too. She told me had I not given it to her she would have asked any way. No harm no foul, I guess, but I will hold a dose of laxative in a hot second now. It is something that will always stay with me.

As far as other med errors go, at my hospital it is policy that all injectables be verified by another nurse. It really doesn't take that long to do and I personally have seen quite a few med errors avoided because of this system.

Wanda