First medication error & on new graduate orientation :(

suanna · Apr 30, 2010

You'll get over it. Every nurse makes med errors. Some errors are more dangerous than others. This isn't going to be your last one- All you can do is take the most care you can and when a med error is discovered follow the appropriate steps. Who knows, you could be a change agent for med policy in your hospital if you find you are having close calls over the same issue more than a few times. For instance- why is a BID med being given at such different times. It is begging for a med error to have med passes for twice daily meds at suck irratic schedules. At my hospital it is the rule that after the first dose of an ordered med (with a few exceptions) the med schedule is adjusted to standard times. If both your patients got thier Deca at 10:00 and 22:00 there is no way you could have made that error. E-Mar is ok only as far as it goes. Joint Com. seems to think by taking the meds and bar coding them you are going to eliminate errors. From my observations it makes more errors- with pharmacy, the nurse and now the computer making decisions on how to set up the med schedule- it is just more and more chances for errors. Take a deep breath , remember you med pass rules, and look forward not backward.

krenee · May 1, 2010

I've been a nurse almost 9 months now and just made a big mistake . . . I meant to d/c an iv and I stopped the pump, but disconnected the PCA line instead :uhoh3: . The patient wasn't getting her morphine and the pump was administering it into the little pan I left it sitting in. It was a horrible mistake, and the doctor was the one who found it - NOT happy. I had already gone home when it was discovered and didn't find out about it for a few days, but I'm still pretty upset about it. I've been talked to about it by the two charge nurses but not yet the "official" talk which I'm sure I'll get when our director gets home from vacation - but I figure a talking to is the least I deserve.

I guess the only thing I can say is be careful all the time! There are so many ways a mistake can be made that it's downright frightening. Yes, we will all make them and it is important that we learn from them, and own up to them too. There were students that had the patient later that morning and I could have blamed them, but I'm certain it was my mistake and I'm not going to throw someone under the bus like that - so while my reputation may be tarnished, I will keep my integrity.

Sunnysidegirl · May 1, 2010

I am a fairly new nurse (the possibility of making a med error scares the crap out of me!)and during my orientation I gave a full dose of po phenergan 50mg instead of 25mg.I didn't cut the pill.I noticed the correct dose as I was charting.My heart sank and pulse rate soared.I told my preceptor right away called the MD and wrote a QVR,and checked on the pt about a thousand times, how humiliating.Worst thing about all this was is that the pt had been too sedated and the dose was halved for that reason.I had been so careful with this pt all day judiciously giving pain meds and anything that may oversedate.Yikes.I thought what an idiot I am.I thought I was being so carefull! The pt was o.k. no harm done.I traced my steps leading up to the error and realized I was rushing!NOW I DON'T I block distractions from my mind and focus only on the pt I am giving meds to and the 5 rights. I check, recheck ,and check again and I too do the walk into the room and walk out to check again thing!!!!!!!(I thought I had OCD until I read other posts!!!:)

I take the time to get it right and unfortunatey I seem to be getting out later than other nurses.I hope as time goes on I can pick up my pace w/o comprimising safety.B/c that med error is as fresh in my mind as the day I made it and I wont cut corners or rush again!

My nursing instructors words are also stuck in my head "Once you give it you can not take it back..."

suanna · May 2, 2010

I've been a nurse almost 9 months now and just made a big mistake . . . I meant to d/c an iv and I stopped the pump, but disconnected the PCA line instead . The patient wasn't getting her morphine and the pump was administering it into the little pan I left it sitting in. It was a horrible mistake, and the doctor was the one who found it - NOT happy. I had already gone home when it was discovered and didn't find out about it for a few days, but I'm still pretty upset about it. I've been talked to about it by the two charge nurses but not yet the "official" talk which I'm sure I'll get when our director gets home from vacation - but I figure a talking to is the least I deserve.
I guess the only thing I can say is be careful all the time! There are so many ways a mistake can be made that it's downright frightening. Yes, we will all make them and it is important that we learn from them, and own up to them too. There were students that had the patient later that morning and I could have blamed them, but I'm certain it was my mistake and I'm not going to throw someone under the bus like that - so while my reputation may be tarnished, I will keep my integrity.

At least the little pan was comfortable! Big mistake-!? no one died. MISTAKES HAPPEN. Accept responsibility for for the error but keep in mind that even when you are doing your best, mistakes will happen. The important thing is to recognize the error as soon as you can and take steps to make sure the least harm comes from any error that happens- They will happen. Nurses have got to stop flogging themselves whenever thay fall below the level of perfection. Do a good job. Be careful and know that the good you do will far outweigh the bad. But accidents are just that - accidents. Unless they give you your own private entrance to the morgue from so much use, try not to see every error that happens as some personal failing that needs to be stamped out.

fiveofpeep · May 3, 2010

for the future, can you print out the MAR and make sure to check the name and mr# or acct # and DOB so you know without a shadow of a doubt you have the right patient? maybe I misunderstood, but how you wrote it, it makes it sound like you prepare all your meds outside of the room and dont bring the MAR with you to actually administer them. if thats so, you definitely run the risk of giving the wrong meds again. Im glad everything is working out with you and the patient is okay

nursgirl · Jul 20, 2010

I am SO glad to hear I am not the only one who's made an error based on a decimal point... I am finishing my orientation in an ICU.. new grad... MD wrote for Enalapril 6.25mg IVP... I gave it and somehow it didn't enter my brain that the decimal was in the wrong place!!! it should have been 0.625mg! The NOC RN gave it also... pharmacy didn't catch it until they couldn't figure out why we ran out of vials of Enalapril... FINALLY the mistake was caught! I am SO grateful the patient is absolutely fine... but the minute I was made aware of what happened I wanted to run out of the unit, throw up, and turn in my RN license and go back to school to do something less "life and death".. LOL. My charge RN said she watched the blood drain from my face and asked me to sit down... she kept reassuring me that EVERYONE makes a mistake at some point.. she told me if I ever met an RN who claimed they hadn't made a mistake that they were full of $hit... hahaha. She also told me our patients often survive in spite of all we do to them... and she told me I AM a good nurse and that I am human and that she was willing to bet I wouldn't make that error again! I learned another VERY valuable lesson... if you have to pull more than one vial out of the Pyxis then that is a huge sign that something could be wrong with the order... I had to use 3 vials to draw up that much Enalapril... sometimes where I work we DO need to draw up alot of medication for certain things but at the time something in my gut was telling me this wasn't right... I also learned to LISTEN to that gut of mine... Doctors are NOT PERFECT. I think as new grads especially we tend to look at physicians like they know everything because they know so much more than we do. LOL well physicians make mistakes too...

Anyway, I still feel like I want to projectile vomit this morning but I keep reminding myself that I am a new grad working in a high stress environment and that I am human and NOT perfect and the patient is totally fine (THANK GOD) and that I need to turn this into a learning experience... just because we check our meds against our MAR against the patient, etc 5 times does not mean a med error can't happen... take my experience... if you don't KNOW that you KNOW that you KNOW that it's the right dose then double check! You can BET I will be!!!!

AnneS · Jul 28, 2010

I am a new grad on a med surg floor. We have an emar and everything is computerized. I see all the nurses read the mar on the cow, pull their meds, then walk into the pts' room with their brain and admin. the meds. I am so not comfortable with this. Bringing the cow into the room would be a real hassle as they are shared by a few nurses and the rooms are double occupancy and there is no room for wheeling it in without moving a bunch of chairs/trays/iv poles etc..so I understand why the nurses do it the way they do, but still I am freaking out that this is a good way to make a mistake...Any suggestions as to how to admin meds safely using this method? Thank you.

mandyc · Jul 28, 2010

I print my MAR's and take them into the patients room with me. I go over all of the medications with them during the begining of the shift and go over administration times, dosages and their plan of care. Be carefull not to leave the MAR out or in the pts room as this can become a privacy issue, HIPPA! There is nothing worse then not checking.Just make sure the MAR is up to date with the physician orders/records. We have a CARET system in our hospital which we scan all of our meds prior to the patient receiving them, that helps as well to lessen the med errors.

AnneS · Jul 29, 2010

Thank you, I was also given that suggestion to print the mar at work today when I asked the lead. I will certainly do that tomorrow.

FiduciaRN · Jul 29, 2010

Yes, we all do make mistakes and just need to use it as a lesson learned. I've made a few silly mistakes, but I've also caught mistakes by seasoned nurses. One night at my old job, I went to pull captopril 12.5. I notice as I'm about to open it, that is says carvedilol 12.5. So I called pharm to get the right med brought up. The pharm informs me that there is noway she sent up the wrong drug, and that it must be my mistake. It wasn't. I'm very anal as well when it comes to passing my meds. I couldn't say for sure if any other nurse prior to me gave the wrong drug. So unfortunately I couldn't report it, and it made me feel like crap. One day I hung up the wrong dose of Vanco. I didn't even notice it until my relief pointed it out to my preceptor. It seems as the RN prior never gave him his first dose, so that's the dose I hung. I wanted to cry bc it was my first week in the ED. The docs there can't stand me. I never give a med unless I see the order with my own two eyes and they get mad. I do this, because I don't like taking verbal orders at all. The reason for this is bc one night a doc told me to push 40 of Lasix. I repeated back 3x to make sure I heard him. Well when I asked him to write the order he said, why did u push it. Ummmmm bc u told me too. He said I will write the order anyway, but I realized he shouldn't have gotten it. Gee thanks.

bbie17 · Jul 30, 2010

Like others said, don't beat yourself up on it. The important thing is you've learned from your mistake. And it's okay to feel incompetent and nervous because that will allow you to be more cautious of what you do.

Everything is computerized at my hospital and we give meds using a computer scanning system. We scan the patient's ID band before giving med to pull the patient's profile up on the computer. We then scan the medication barcode. If you pulled the wrong med, had the wrong dose or tried to administer the med at the wrong time, a pop-up message will alert you on the computer after you scanned the med. And lastly, we scan the patient's ID band again to confirm the right patient. This system is great and one might think how can a medication error occur with a high tech system such as this one? But it still can...!!

A few weeks ago, my preceptor and I were in a pt's room to give insulin. Patient was supposed to get Novolog 70/30. My preceptor gave me a bottle of Novolin 70/30 and I scanned it. A message popped up on the computer saying "Medication not found" for this patient. We double checked the insulin box and didn't see any bottle of Novolog, so we called pharmacy and told them the situation. Our pharmacist told us "Novolin is Novolog, they're the same thing." He told us he'll correct the barcode so the med would scan for us on the computer next time. I had a weird feeling that we weren't going to give the right insulin but my preceptor said to give it, so I did. Later that day, we called our pharmacist again to double check on the Novolin and Novolog...and again, he told us it's the same insulin.

Next day, another nurse had that same patient and she got a bottle of Novolog brought up from the pharmacy for this patient. I spoke to her about what happened the day before and she said the pharmacist whom she spoke with told her the two insulin were different and that's why they sent up the right one. I panicked and went looking for my preceptor when conveniently I ran into the pharmacist I spoke with yesterday. Again, he told me Novolog and Novolin are the same!!

After a while, as my preceptor, charge nurse and another nurse were trying to figure out this insulin situation, the pharmacist whom I spoke with came up to us and apologized. He admitted he had made a mistake, they were NOT the same. From what I've heard, he's been a pharmacist for a long time...so mistakes can happen even to people with the most experience.

From this experience, I learned not to depend on what others tell you. Trust your own instinct, go to your coworkers for help but when in doubt, refer to a literature.

MicsterRN · Aug 26, 2010

I happily went to work on my day off just to peak at September's schedule. I'm a new grad and have only done three new admissions, so I asked the DON in passing if there were any problems or suggestions for improvements from my admission this past week. She said, "I'm not sure about the admission. But I'm glad I saw you; I just need to talk to you about your med error from Sunday." I was NOT ready for that one!

Two residents w/ same first name, same med, different dosage. Yowsers! Wrong dose . . . actually wrong patient. But the resident had the same med and I grabbed from the wrong box.

The DON consoled me with, "A nurse that claims to who have never made a med error is a liar or has never worked as a nurse." Since the unknown is our enemy, and I was informed about the med error after the we already know that no harm was done by my error, I'm taking it all in stride. I still would rather discover my own error than have somebody else uncover my error - I think that's what stung a bit more. The fact that my mistake gave them something to talk about for an afternoon or so, well, glad I could help out and fulfill the need for gossip!

I fear my own incompetence. (If I'm scheduled for a 6am shift, my ridiculous anxiety disallows me from sleeping the night before.) I fear, even more, somebody else viewing me as incompetent. I'm a nurse to help in healing or dying, but I'm now questioning after two months, shouldn't I be better at this by now?