First medication error & on new graduate orientation :(

LittleWing21, RN · Mar 12, 2009

It's ok!!!!!!!!!!!!!! We are human after all. And they're right, you will surely be more careful with looking at the right EMAR from now on. I love computerized documenting, but the whole "wrong pt's chart" thing is sooo much easier to do on the computer. It's not like you're physically going and getting their chart, and it is very easy to be accidentally looking at the wrong one.

I try hard to really think things through before I pass my meds: why is this person getting this? they're getting it often, are they getting too much? I have even walked right out of a pts room with all they're meds in my hand because I second guessed myself. I've said "hold on, I just need to go check something," i look at the EMAR then go right back. This is hard to do with 6 pts, but better than a med error! The other nt, I even had 2 female pts with the same last name in rooms right next to eachother! Talk about an error waiting to happen!!

Accidents do happen, and like you said, there was no harm done. And that's what really counts. Live and learn!

SummerGarden, BSN, MSN, RN · Mar 12, 2009

i am like the above poster. i check my medications against the mar so many times (and the patient) that i drive some nurses nuts (oh, well)! the reason i do this is because i have the fear of making a medication mistake. in fact, the other day a patient's family member thought she saw me give two of something i only gave one of... since i check myself a million times i know i did not give two of it even though i brought two in the room (one medication was sharing a bag with others of it's kind and was not labeled otherwise. at the bed side i pulled out the right dose so i could triple check the 5 rights). she was the type of person who would have accused me of something i did not do... btw, i figure every patient and family member is that way so that keeps me on my toes.

i do not have an emar. there are only a few departments in my hospital who are electronic... however, i floated to a department with an emar that is not at the bedside. in that case i triple check at the computer (pull all my meds and proper doses) and took very few meds into the room at a time so i knew literally which pill was what... i am not comfortable with taking 25 medications into a room without a paper copy of a mar!!!

do you have emar and a paxis next to the bedside? if so, then i would treat that in the same manner i treat my paper mar. my third and final check can happen at the bedside.

in nursing school i used to be worse... i used to check the patient when i entered the room... checked the papient while doing my third check of 5 rights... and checked the patient before handing the patient his/her dose. and yes, this drove my instructors nuts... i realized by fourth semester that was a bit much.

-new grad rn:nurse:

ps.

also, i agree with the above poster that you are human take this as a learning lesson!!! those sick feelings you now have will more then likely prevent you from making any more errors in the future! i had an instructor who once told me that when you no longer have that small sense of fear of making errors is when you will make them... so now you will never be without that sense of fear.

also we are learning... nursing school is nothing like being a new grad! the expectations are high in nursing school but they are even higher with the rn title next to your name. not to mention the amount of learning we have to absorb in a short amount of time and apply at the bedside (the true test)! some days i feel like the most competent new grad around... other days i am reminded painfully that i am only a new grad. good luck to you and keep on posting... all of us will get through our first year together!

azhiker96, BSN, RN · Mar 12, 2009

Don't feel incompetent. I think we've all made errors. When I started in this career a seasoned nurse told me "Our patients survive in spite of what we do to them." The message being that even with the best orders and best caregivers we sometimes make mistakes but usually they do no harm.

Now, think of all the things you did right that day, that week. An incompetent nurse could not have done so many things right. Use this as a learning experience and I'm sure you won't make that mistake again.

Two years into my practice I was still reading every med label when I pulled it from the pyxsis, even the narcs that have only one drawer that opens. I thought to myself that maybe I was a little OCD. Then a good friend, 30yr+ nurse, had a med error. She drew a tubex of Dilaudid from the Pyxsis and gave the pt. a dose. As she pushed the dose she noticed the name on the tubex, Demerol. WHAT!?!? Horrified, she went back to the pyxsis and checked the record. It said she'd taken out a Dilaudid. She grabbed our CM and together they checked the Pyxsis. Pharmacy had mistakenly stocked Demerol into a Dilaudid drawer. Pharmacy corrected their stocking error but my friend got to do an incident report, med error, and call the Dr. who had not ordered Demerol for the pt. Happily, the pt was not allergic and there was no harm done and the Dr. said it would be okay. Now I still read every med label but I don't worry that I'm OCD. It's just CYA!

gardenia09 · Mar 12, 2009

"do you have emar and a paxis next to the bedside? if so, then i would treat that in the same manner i treat my paper mar. my third and final check can happen at the bedside." -mbarn08

my unit has the med pyxis in a locked room and then 2 portable tablet emar (that was out of order at the time) and then 2 portable computer flows, or cows. so i looked at the emar on a computer at the nurses station, apparently read the wrong one, and then went into the pyxis, pulled the med, went to the patients room and grabbed a flow/cow on the way in and gave the med to the patient, check the emar again, and realized it wasn't due. you guys are right, i should have checked the emar again before i gave the medicine. the messed up part is that i had been doing that. so the first time i changed my system there is a problem. :banghead:the tablet emar is very annoying, the stylus is not in sync with the screen half the time and you have to scroll to the right date and time every time. i am just going to have to take my time and do as many checks as possible. it just sux cause i know everyone is gonna find out and think i am an idiot.

ANH_RN · Mar 13, 2009

Don't feel incompetent. I think we've all made errors. When I started in this career a seasoned nurse told me "Our patients survive in spite of what we do to them." The message being that even with the best orders and best caregivers we sometimes make mistakes but usually they do no harm.
Now, think of all the things you did right that day, that week. An incompetent nurse could not have done so many things right. Use this as a learning experience and I'm sure you won't make that mistake again.
Two years into my practice I was still reading every med label when I pulled it from the pyxsis, even the narcs that have only one drawer that opens. I thought to myself that maybe I was a little OCD. Then a good friend, 30yr+ nurse, had a med error. She drew a tubex of Dilaudid from the Pyxsis and gave the pt. a dose. As she pushed the dose she noticed the name on the tubex, Demerol. WHAT!?!? Horrified, she went back to the pyxsis and checked the record. It said she'd taken out a Dilaudid. She grabbed our CM and together they checked the Pyxsis. Pharmacy had mistakenly stocked Demerol into a Dilaudid drawer. Pharmacy corrected their stocking error but my friend got to do an incident report, med error, and call the Dr. who had not ordered Demerol for the pt. Happily, the pt was not allergic and there was no harm done and the Dr. said it would be okay. Now I still read every med label but I don't worry that I'm OCD. It's just CYA!

"I never want to be that nurse that doesn't double check everything"

Great words spoken from one of my preceptors, will always, ALWAYS stick with me. I repeat that sentence in my head pretty much every single day.

starletRN · Mar 13, 2009

We are human and mistakes will happen. Even seasoned nurses make mistakes. Maybe this thread will make you feel better.

https://allnurses.com/general-nursing-discussion/med-errors-share-370373.html

nicu4me · Mar 13, 2009

I had an instructor say that we will all one day make a med error. It's taken me a over a year, but I finally made one. And it was a big one. Pharmacy sent up the wrong dose, the tech filled it the pharm D., initialed it, I did the 5 rights 3 times, another RN cosigned it and it was given. The error being the dose. I had a bad feeling about it, luckily there was help available but trust your gut. And as far as the others thinking you aren't as good as you should be, I think we all know that we are just one med away from making an error. Best thing to do as I did is admit it and not make excuses for it. I still feel bad but I had support from the manager and the MD. Will I ever make another one? Maybe, but it won't be because of a decimal. You'll feel better in a few days.

Jules A, MSN · Mar 14, 2009

Sadly mistakes happen. It took me a while to feel comfortable with med passes as a new grad but it does get easier. Imvho a nurse that says they have never made a med error is either a liar or worse has made errors that they aren't aware of. Sending hugs and good vibes your way, Jules

gardenia09 · Mar 14, 2009

you guys are awesome! i do feel better, but i passed meds today (mostly iv) and i did quadruple checks today! lol i had to push lasix and nexium for a patient and tube feed meds. i went in the room and my preceptor had given my the rundown on all the meds but 15 mins later, she came in and said "are you finished?" i said "no still checking everything" she just smiled..because she knew what time it was, i am not playing.

:lvan:

SummerGarden, BSN, MSN, RN · Mar 14, 2009

you guys are awesome! i do feel better, but i passed meds today (mostly iv) and i did quadruple checks today! lol i had to push lasix and nexium for a patient and tube feed meds. i went in the room and my preceptor had given my the rundown on all the meds but 15 mins later, she came in and said "are you finished?" i said "no still checking everything" she just smiled..because she knew what time it was, i am not playing.
:lvan:

good for you!!!! :yeah: welcome to the driving-your-preceptor-nuts-because-you-check-everything club. :up:

i'm so proud.

NeoNurseTX, RN · Mar 14, 2009

It happens to all of us and at least you caught it. What I'm scared of are the things that I DON'T catch! If someone else catches me in an error, I hope they let me know! We're human... I've never made the same error twice (to my knowledge) but I seem to always create new ones...