Medication error... ALMOST.

  1. I'm a new nurse, 3 months and counting. This happened a week ago. I had this 60 y/o DM male patient who had a cellulitis on the left lower extremity. I assisted the doctor in doing I&D inside the room. Pus. Lots of it.

    (I heard later that the patient's wife knows the doc's mother personally so they agreed to do I&D inside the room to not add up the financial burden of going to OR for such minor surgery.)

    Afterwards, she ordered to give ATS (anti-tetanus serum) 3000 units IM after negative skin test and TeAna 0.5cc IM.

    So okay, I explained to the patient the new meds I'll be giving. I told him I'll have to inject those meds on his arms. Then I did a skin test for ATS and injected the TeAna on his left arm.

    After 30minutes, I went back to check the skin test.. and called the ROD. It was negative. I had the ROD signed the chart.

    Then I went back to the patient. There was a side drip antibiotic on the main line so I removed it first. Then the next thing I remembered, I inserted the syringe with the ATS on the main line tube!!! OH MY GOD!!!! I don't know what happened but I just realized that I've already inserted it there!! Good heavens!!

    I was so relieved that something inside me stopped me from pushing the syringe... I was ONE PUSH away and I'll have my first ever med error as RN!!! :smackingf

    I immediately withdrew the syringe from the tube.. and said to the patient that I'll just go back to get an alcohol swab from the station.

    I went back to the room and asked for the patient's name again, and told him I have to inject the med on his right arm.

    He said kindly, "Yeah. I was wondering why you put it in the tube? I thought I heard you telling me I'll have both meds injected on my arms."

    All I replied was "Oh." Then told him to inhale because I'm about to inject the med. I said "thank you, sir" when I was about to leave the room.


    I never admitted to him that I almost made a mistake. I don't want to lose any patient's confidence in me.

    He was discharged a day after.
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    About fiery_ai

    Joined: Aug '09; Posts: 9; Likes: 3


  3. by   fiveofpeep
    thanks for reminding us all of the huge importance of not only remembering to check the med and the pt, but also of checking the route
  4. by   HeartRN_09
    Well the good thing is you caught it. I've made a few minor med errors myself. It's just something that will happen, you can count on it. Especially with meds that you don't give routinely. I pushed something IV once that was ordered IM. It can be given both ways (Thank God!). I now check all my meds 3 times for drug name, dose, and route before giving it to the pt. Haven't had an issue since I started doing that. lol.
  5. by   fiery_ai
    My first, and hopefully the last, med error happened when I was a nursing student. I was in my 3rd year then, assigned in the ward.

    I gave a whole tablet to a patient.. I forgot what it was. But it should have been cut in half.

    I only realized my mistake when I was about to throw the med foil.. I read it and read the medication ticket, and realized that I gave twice the dose of the ordered med.

    I immediately told my clinical instructor about the incident. Afterwards, we reviewed the MIMS for any adverse effects of the overdosage of the drug.

    I continued to monitor the patient the rest of my shift. No adverse reactions, thank God!! Good thing, it was only a tablet.. still, you can just imagine my fear as a student.

    From then on, I always check the stock dose of any ampule, med foil, vial.. And so far, I'm doing well.. except for this one. Another medication error... almost!!!! Lol.

    Seriously, I believe that one really learns from past mistakes. I'm praying that I won't make any medication error in the future.
  6. by   Nire83
    Phew! Good thing you had a nursing angel on your shoulder! I can totally picture that happening and that wave of shock coming through you as you were JUST about to push it. Good instincts!
  7. by   mustlovepoodles
    Good catch~ Everyone makes a med mistake sooner or later. You try your best to always do the 5 rights, but sometime something will slip by you and a mistake is made. We always hope it will be fairly minor. But to think you will go through your entire career mistake-less? That's a mistake.