2 drug errors in the last year

[mmsparkle]

Hi guys.

I made my second drug error within a year last night. Fortunately the patient was unharmed. I didn't even notice it myself, it was pointed out to me.

Needless to say, I wrote it up on an incident form, documented it, informed the staff now looking after the patient, informed the doctor, etc.

I just can't believe I could have been so careless. The patient had a raised INR and was written up for IV Vitamin K, 3 doses on 3 different days. I gave all three doses at once. STUPID! I thought at the time it was odd. checked again, checked the dose, missed the date.

There were many contributory factors, but at the end of the day it's my fault, I didn't check the chart properly or even query the 'odd' dose.

Thankfully, the triple dose had no effect on the patient's INR (it was raised still further the next day).

My main concern is that it will happen again. I'm usually very consciencous (sp?) but certainly the situation could happen again (understaffed, night shift rotation, me being tired and stressed, understaffed late shift unable to give meds at time prescribed, pt on many IV meds).

Obviously this has given me a jolt, and I will be making darn sure I don't give ANYONE any med unless it is absolutely correct on all 5 points.

I'm also about to start a new job - I really don't want to have a reputation following me of many drug errrors!

Thanks for 'listening'.

[CaLLaCoDe, BSN, RN]

If you give IVP vitamin K make darn sure you push it slowly; one of our patient's nearly died of a MI from a doctors "push the vitamin K stat order."

I can't remember why he ordered it, possibly to prevent a hemorrhage at a hemaquit site>>????anyway subques my favorite route for this baby

[Kabin]

HIPAA Compliance Journal: Medication Errors - Startling facts and figures

"There is an average of one medication error per patient per day in hospitals alone."

[mmsparkle]

Well, my thanks to all who answered me with such graciousness. I certainly felt better later. (The patient was fine).

I have transferred to the new job now; it's an area where every IV drug gets double checked. I'm much happier about that.

I still feel that two IV drug errors in a year is fairly serious, however. I'm not talking about a med being given late, or even omitted due to lack of stock - these things happen all the time in every area I've ever worked in.

I'm doing my best to learn all the new medications used in my new job so I can be familiar with usual doses etc.

Anyway, thanks again. I appreciated your support.

[SCRN1]

I agree with the others about not beating yourself up about it & to learn from your mistakes. Sometimes making a mistake where no one is hurt is a good thing...I think so anyway. Because it'll stick in your mind from then on and make you a more careful nurse in the future and will hopefully prevent you from making a more serious mistake with someone else.

Congrats on your new job and good luck with learning the new meds there. It does seem like each place you work there are a whole new bunch of meds routinely given that you have to relearn, doens't it!

[AfloydRN, BSN, RN]

Don't be so hard on yourself. It happens to all of us. The longer you do the job, the easier it is to miss something. We get in such routines about meds. It is easy to make mistakes. We all do it one time or another.