Gave vancomycin wrong

Nurses Medications

Updated:   Published

So yesterday I made my first medication error with vancomycin. I had two vials of antibiotics and one was meant to be IV push and the other was meant to hang via infusion. I mixed up both antibiotics and accidentally gave vancomycin IV push.

I instantly realized I made an error.

I assessed the pt and she was fine. I notified my charge nurse and wrote a variance on it. My supervisor was also notified of the medication error. I felt so stupid and dumb for letting something like that happened. I always double check my work but this time I failed. I called the night nurse to see how the patient was doing and she said was fine although that 4am she complained her IV hurt and it was a little swollen but no redness noted. I had given vancomycin around 4pm IDK if that could have caused it. So they D/C the IV and gave her ice. The patient said she felt much better.

As for me, my confidence has gone low. My supervisor told me I could of loose my license over this. Which made me feel even worse. The charge nurse told it was fine, the patient is fine and to take this as a learning experience. This is my third week off of orientation so I’m still adjusting to the environment. I take full responsibility for what happened but I feel so bad about it.

5 hours ago, myoglobin said:

Vanc isn't given IV push, but it also isn't "mixed" (we have to mix ourselves in bags).

Ah. OK. I misunderstood what the poster said.

Specializes in ER.

Scanning the patient's bracelet, scanning the first antibiotic, scanning the second antibiotic, the medication checks in your head, thinking about your other patients, thinking about what you are gonna do next, it's tough!

I give one medication at a time and let the rest of the meds sit on the computer on wheels.

Specializes in Informatics / Trauma / Hospice / Immunology.

Usually when an error like this happens, it is due to multiple mistakes. For example, why was the drip scheduled at the same time as the loading dose? Why wasn’t the vial for the IV bag attached to the bag? Was there bedside scanning to check the barcode vs the order? I think guest covered the checks. This really is the point of the variance report to see how multiple safety checks failed, not just human error. I will say that new pumps automatically get programmed as you scan the patient and med so at least the rate is safer. 

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