First medication error... And the last.

[AnthoScott]

So I was in clinicals in the ER the other day and I had a pt who was dx with appendicitis and needed some pain relief. The Dr ordered 40 mcg Fentanyl IVP. So I went and drew it up and double checked it with my nurse. The Dr was standing there and he said "actually go ahead and just give him the full 50." So I went back and drew up the rest of the dose. Since we don't scan meds in the ER, I threw the vial away after I was done. We went in and I pushed the Fent. We then went up on the floor to start an IV for one of the nurses up there. As we were walking my preceptor asked me what I did with the vial after I was done. I said I threw it away because it was empty. She stopped. I stopped. She then asked, "So how much Fentanyl did you just give our patient?" I remembered the dose on the vial was 50 mcg/ml and it was a 2 ml vial. My heart stopped beating for a second. And as I doubled over in shock I uttered "100 mics." So we went back down and I assessed my pt and he was doing very well and said his px was much better. My nurse then took me aside and said "I know you didn't push 2 ml's in his IV. I watched you push it." I didn't believe her and I was still freaking out about it so she went digging through the trash and pulled out the vial which had 1 ml still in it. I was so relieved and that's when the tears came. I had never cried in nursing school up to this point. And I cried hard. I know Fent is a pretty forgiving med, but that's not the point here.

What I did wrong/What I learned:

1. I drew up the other 0.2 ml of that vial without my preceptor. Should not have happened.

2. I can't remember double checking the second time. Also bad. I will always always always double check from now on.

3. I didn't read the label on the vial before drawing up the med the second time. I don't care how many times I've drawn up a med, from now on, I will always read the label and make sure my calculation is right before I even leave the med room.

4. I did not waste properly. I should have wasted the medication down the sink with another nurse and my preceptor before I ever threw that vial away. Never again.

this had such a profound impact on me that I know that I will never make this mistake again. Why? Because I will follow the rights of medication administration. Forever. And I will ALWAYS keep this in the back of my mind: once you push a med into that IV, it's gone. You can't get it back. So you better be damn sure you're putting the right medication in the right dose to the right patient at the right time.

thanks for reading. :)

[eschroeder]

Thanks for sharing!! I also work in an ER where we don't scan meds and I'm always afraid of making a med error. You owned up to it and learned from the mistake. That's admirable.

[Purple_roses]

I would have cried too! How stressful. Thank you for sharing your story and what you learned. Not only will the experience help you to be more mindful in the future, but it will hopefully remind us fellow students to be careful too.

[EmiliaMaria76]

Thank you for sharing your story. This will help everyone, especially students, realize how easy it is to make a med error. I have learned from reading this post and I will definitely be more cautious and probably do more med checks now.

[CBlover, BSN, RN]

I would like to add, I do not feel like Fentanyl should at all be in the "very forgiving meds" category. It is a very potent, fast-acting, dangerous opiate with profound effects on the respiratory system. And I know the scary feeling. Your heart literally feels like it stopped. Glad everything was ok. Good example of a learning experience.

[dexm]

This EXACT same thing happened to me when I was in my ICU internship as a new grad. All I remember reading on that vial was 50 mcg/ml…completely ignored the "2 ml vial" part. And I definitely pushed all 2 mls when the order was for 50 mcg. Thankfully nothing happened to my patient! Definitely a learning experience though!

[missmollie, ADN, BSN, RN]

While in my final semester of nursing school, I gave a patients two pills that should've been halved. Giving her the whole pill was her normal dose, the same dose I had given the night before, but she was being weaned off the pills to induce a seizure. The absolute panic that sets in when you realize you've given the wrong dose is terrible, but one of the best lessons you'll learn. Thanks for sharing your story!

[Conqueror+, BSN, RN]

Gave Darvocet (man I'm old) that had been d/c'd on the chart but NOT the MAR. Ugh that sucked.

[akulahawkRN, ADN, RN, EMT-P]

And you know what? While you learned a LOT from this mistake, it won't be your last. I survived a med error while in school... and I've survived a med error while working. Fortunately for me (and more so for the patient) the errors I made were generally system errors and not "me" errors and those errors happened to be ones that didn't harm the patient. I may be fast at most things but when it comes to doing meds (and I'm an ER nurse at that!) I do this task a bit more slowly because I know the danger of getting it wrong.

Oh, and while Fentanyl is generally good stuff and usually is forgiving, it's only that way if you push it properly. It's easy to become complacent because it's "just" Fentanyl. Treat it with the respect it deserves and usually things will be just fine.

[amoLucia]

And you know what? While you learned a LOT from this mistake, it won't be your last.

I never wanted to become complacent re med errors. I was always soooo sloooow passing meds. I used to wonder how come all those others nurses I worked with were so fast.

They were good nurses but I could not figure out how they were so quick. Were they cutting corners? Were they omitting meds? Were they giving meds by rote memory? Were they doing some 'creative' signing of the MAR? I just don't know.

We've all caught ourselves on med errors, but I wonder how many we've made that we just DIDN'T catch - that we DIDNT even know we made? Those are the scary ones.

Sheesh, I even worry when I take my own meds ...

[willegan]

Whoa, that's a pretty big lesson to learn. Knowing what to do when a medication error occurs is pretty important though. It's good to see your preceptor helped out in such a calm way, like you say though "never again". You find a few of these articles of use:

Medical error, incident investigation and the second victim: doing better but feeling worse? -- Wu and Steckelberg 21 (4): 267 -- BMJ Quality and Safety

https://www.ausmed.com/articles/investigating-medication-errors/

Australian Open Disclosure Framework | Safety and Quality

[Neuro Guy NP, DNP, PhD, APRN]

I am so glad you learned something from this experience. Medication mistakes can be horrific for both the patient and the nurse. Thankfully, most mistakes result in no patient harm. Anyone in the health care field who says they have not made an error of some kind is a blatant liar. We are all human and not above mistakes.

In the future, I'm sure you'll remind the five rights of medication administration. Your concern shows that you are already an excellent clinician. It takes a lot to admit to a supervisor of some kind (charge nurse, preceptor, manager, whoever) that a mistake was made.

That being said, and forgive me if this sounds bleak, but I highly doubt this will be your last mistake ever. That's just the simple fact of the matter. The important things is to learn from each mistake. Across the next 20, 30, 40 years of your nursing career you along with the rest of us will likely make another mistake. Just remember to learn and grow from each experience and be straightforward and honest.

I'll share a personal experience of mine. I'm a brand new NP, but this experience comes from when I was still doing bedside nursing about 7 months ago in the ER. I had a COPD exacerbation patient who was also ordered Zofran for nausea. Well, the Zofran vial was blue just like the Terbutaline vial and they were next to each other in the pyxis drawer. So what do I do? I accidentally pull Terbutaline and give it. Thank goodness no harm came to the patient, especially since Terbutaline is actually a bronchodilator (in which case it actually probably helped the patient out considerably).

The point is, I should have doubled checked the medication I pulled out of the drawer as I was pulling it out and check it again as I was about to give it. WHo knows? For all I knew it could have been an entirely different medication!! My whole point is that time goes on, and the more experience we get, sometimes we can get lulled into a false sense of security, or rest on our laurels. I think it happens to everyone at some point. And in come the mistakes.

Long story short, stay alert and always stay on top of yourselves. I am sure you will be an excellent clinician.

Good luck to you! Don't beat yourself up too much

:-)