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Discussion

First Screw-upp

So I have a situation. I am a new graduate working in the ER and am still on orientation. I was getting report and the pt I was with started complaining of pain. The nurse I was with said she had 4mg of Dilaudid IV ordered. Not thinking I asked if she would put in the order and get the medicine. She did and I witnessed her giving the IV dilaudid. She signed off in the chart, and I signed it off in the computer. My pt became somnolent and I had to administer Narcan, and then realized that the order was for 4mg dilaudid PO! My preceptor was livid, and I feel like a complete idiot for not checking/questioning the order. I wrote up the incident report, but I am not sure what to expect. Anyone have any advice/been through this?

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    Thats not your screw up/error. The nurse that put in the order and gave the med made the error.

    An order acknowledgement is just that. it is ONLY an acknoweldgemnet that you see the order as it is written or placed oin the computer. Not that it is up to you to carry out do. It is only an acknowedgement of an order recieved.

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    thats not your screw up/error. the nurse that put in the order and gave the med made the error.

    it is partially the op's screw up and error. she said, "

    i was getting report and the pt i was with started complaining of pain..."

    not the end of the world, but a preceptor is going to be a little livid about that. you would question that order if you indeed thought it was iv. the rn who gave the med is ultimately responsible, but you were so close to the situation you get a little heat too.

    again, not a tragedy, but you should do what you appear to be doing: take responsibility for the error and don't repeat it.

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    Forgive me if I have this wrong but when you verify a order in the computer, you are verifying the drug, dose, time , route etc.. is correct and as written.. So, if that is the case, how did you verify it in the computer without the actual order.. That is your part in the mistake....

    Lesson learned, you know now to double check before signing it off.

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    • Author

    So in our hospital the nurses will put in orders that the doctors had written. The nurse before me put in 4mg Dilaudid IV and that is what I signed off on the computer. Basically she typed in the wrong route, but I didn't check the written chart. I have a meeting with my Nurse Manager on Wednesday to talk about the situation and the other nurse will be counseled as well.

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    Yikes, where I work it's pharmacy that transcribes the doctor's order into the pyxis, not the nurses.

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    The nurse that wrote the order put in the wrong med. The nurse you were with read the computer order and gave the med. You just signed off on the computer. I've never work with computers. I don't think that you did anything wrong. In you mind the computer was right, all you did was co sign. You didn't take the order, put the order in the computer,get the med, or give the med. The only thing you did was co sign. You had no reason to doubt the order. Maybe you should have looked in the written chart but that was not your job. If you were to give the med it would be a different story.

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    Aaaaand this is why we should not be using paper charts anywhere for any reason. They need to put their own orders in teh system. Unless your job description is to check the paper chart every time, I wouldn't worry too much. Also, being on orientation will shield you as well.

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    Ouch. Hard call. Where was your preceptor?

    Best wishes!

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    Well, when you sign off on the computer, aren't you verifying that you indeed checked the handwritten order and it is correct?

    It's a system error, there were a few breakdowns in the system. I believe you and the other nurse made what they call a mistake. mistakes happen. I am quite sure you will never sign off an order in the computer again without looking at the original order by the MD again. No harm done and lesson learned.

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    NEVER sign for something you didn't give. I know when you're new it's hard to go by the rules when all around you seasoned nurses are saying oh, this is how we do it....but when you are learning and in fact, forever, you will be safe if you stop and think before you do anything. Nursing 101, don't sign for someone else!

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    Um...the nurse in question co-signed the electronic MAR which is something that most hospitals require with different medications.

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    • Experts
    So I have a situation. I am a new graduate working in the ER and am still on orientation. I was getting report and the pt I was with started complaining of pain. The nurse I was with said she had 4mg of Dilaudid IV ordered. Not thinking I asked if she would put in the order and get the medicine. She did and I witnessed her giving the IV dilaudid. She signed off in the chart, and I signed it off in the computer. My pt became somnolent and I had to administer Narcan, and then realized that the order was for 4mg dilaudid PO! My preceptor was livid, and I feel like a complete idiot for not checking/questioning the order. I wrote up the incident report, but I am not sure what to expect. Anyone have any advice/been through this?

    Well lesson learned...double check everything that you do. I am confused however.....the nurse you were with,SHE gave the drug and put it into the computer without checking the written order.......one thing that you should never do. Then I get confused again. She put it into the computer and you signed off the order without checking and she signed the chart as being given without checking the order. You both were wrong but I hold her responsible for you as she is supposed to be teaching you the right way.....not the way were all know happens sometimes in the real world. Your preceptor was livid bexcause she knows she messed up big time.

    You should be fine. Admit you made a mistake and you will never give and order without checking it again. and say you are sorry. We all make mistakes.

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