Flyin' high in April, Shot down in May

Nurses General Nursing

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Specializes in Psych (25 years), Medical (15 years).

Last week, I got https://allnurses.com/general-nursing-discussion/a-feather-in-1180780.html#post10009831

This week, I made a med error. No big deal- a higher dose of a steroid than ordered- but still, a med error.

As soon as I realized my error, did the wrong thing, I did all the right things: Contacted administration, the NP, MD, monitored the patient and filled out the necessary paperwork.

Patient is fine, coworkers understanding. A humbling experience.

Ever thus...

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Well, at least it wasn't Vecuronium.

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We all make those mistakes. That's something we have to keep in mind when others commit similar errors.

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Specializes in Psych (25 years), Medical (15 years).
We all make those mistakes. That's something we have to keep in mind when others commit similar errors.

Amen, emmylou.

Once, I received a shift report from a new nurse and she had given a larger dose if insulin than was ordered. She did all the right things- contacted the MD, monitored the patient, etc- and relayed the situation to me, the oncoming nurse. She told me how terrible she felt.

I responded with something like, "We all make mistakes- it's what you do afterwards that matters, and you owned up to your mistake and followed through appropriately. That says something about who you are: a person of integrity".

So I had to remind myself of what I had told another. But still, you know...

I sketched this cartoon in my pocket journal later on in the night:

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Specializes in Psych (25 years), Medical (15 years).
Well, at least it wasn't Vecuronium.

Yeah, Wuzzie, it could have been worse. But still-yet-and-all, I made a med error.

Sometimes, we're on the top of our game and others times we're not.

Or as I drew in my pocket journal, quoting The Stranger from "The Big Lebowski":

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Or, as Frank sang, "That's life!"

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Specializes in Travel, Home Health, Med-Surg.

Yep, we all make mistakes. I once gave a patient (as requested) half the ordered Ativan dose. Once pharmacy caught wind of that I thought the world might end. I thought, at the time, we could give less of the PRN but not more, guess I was wrong, live and learn!

Don't worry DaveyDo, I know 'you are gonna change that tune and be back on top in June', Yep, that's life!

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I have made my fair share of med errors. I must wonder .. what was the root cause of your error?

Wonder where the pharmacy check was, and how you got your hands on a higher dose???

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Specializes in Psych (25 years), Medical (15 years).

I just got off the phone with my supervisor who wanted to discuss the med error with me. It seems that there have been other similar errors due to the pyxis dispensing process. My supervisor, other administrators, and pharmacy are looking into the situation.

My error was partially a result of me not directly examining the med packages and going on the word of the pyxis and the computer.

This will not happen again. I will be more vigilant in the future!

Don't worry DaveyDo, I know 'you are gonna change that tune and be back on top in June', Yep, that's life!

Amen, Daisy!

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I just got off the phone with my supervisor who wanted to discuss the med error with me. It seems that there have been other similar errors due to the pyxis dispensing process. My supervisor, other administrators, and pharmacy are looking into the situation.

My error was partially a result of me not directly examining the med packages and going on the word of the pyxis and the computer.

This will not happen again. I will be more vigilant in the future!

Amen, Daisy!

I see. You did not follow the right dose part of the 5 rights. It is easy to count on the pyxis to give you what is ordered. Think we all count on technology too much.

I was lucky to have a good instructor. She told me to NEVER administer something that was handed to me, even if it was another nurse. Very easy to do in a code situation. Is this a bolus of Epi.. or a bolus of atropine? I have actually caught that while my hands were shaking and was handed the wrong drug.

Even us oldy moldies , highly experienced nurses can make a mistake.

Thanks for sharing... so we can all still learn.

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C'est la (nursing) vie.

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Specializes in LTC, Rehab.

We've all done it, bro ... glad it wasn't anything super-significant.

Speaking of - and I always add this qualifier before I say anything negative about nurses I'm working with, and that is "I'm not perfect either", but on my last couple of work days, on 2 different units - therefore 2 different med carts - I found numerous instances of dc'd meds still in the cart, completed antibiotics (like 1-2 left on a card) still in the cart, and two different strengths of meds for the same patient still in the cart. Oh, and duplicate orders still in the system. Atb orders without a stop date in the system. Need I go on? I probably spent 30-45 minutes each one of those days just fixing stuff. And they wonder why I'm there late...

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Specializes in Psych (25 years), Medical (15 years).
Well, at least it wasn't Vecuronium.

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