I made a medication error. What will happen to me?

[whyohwhy]

Hi fellow nurses,

I self reported a medication error. While administering a scheduled narcotic, an opiate, I accidentally pulled a different, similar dosed opiate. The packaging on the two was very similar and there were many distractions at the time. As soon as I realized an error had been made I notified the MD, monitored the patient, wrote notes, filled out an incident form, etc. In all my years as a RN, I've never been involved in any incidents like this. How worried should I be here? (The patient was fine, though I know that does not mitigate the Med error)

[djh123]

I wouldn't be that worried. You did all of the right things. And if you've never made an error that you know of, you're ahead of most of us. I don't even think I have to add that the only real thing to do is to realize how and why it happened and make changes accordingly.

[chacha82, ADN, BSN]

If you have a good rapport with your DON & Admin, use this as a chance to talk about med errors at your facility and do "root cause" to see what can be done to prevent them from happening.

[whyohwhy]

If you have a good rapport with your DON & Admin, use this as a chance to talk about med errors at your facility and do "root cause" to see what can be done to prevent them from happening.

This is part of where I am stumped though. There were definitely elements of fatigue, distraction, rushing to give the med tech her space back, having two different medications with very similar packaging, etc. But at the end of the day I know this was simply a human error that I committed because those elements I described above happen every shift and I don't make a mistake like the one I posted about here.

[Workitinurfava, BSN, RN]

Take your time when giving meds (do it reasonably).

[Crystal-Wings, LVN]

Should I fear any licensing repercussions?

No way Jose!

[TriciaJ, RN]

This is part of where I am stumped though. There were definitely elements of fatigue, distraction, rushing to give the med tech her space back, having two different medications with very similar packaging, etc. But at the end of the day I know this was simply a human error that I committed because those elements I described above happen every shift and I don't make a mistake like the one I posted about here.

The fact that errors don't happen everyday shows how diligent you are, in the face of many obstacles. That one finally did was probably inevitable. There needs to be some system changes.

[Leader25, ASN, BSN, RN]

Hi,well you handled it correctly,stop beating yourself, you have gotten some very good advice here,

the only thing I can add is stop talking /discussing with anyone ,and i mean anyone on your unit,it will all blow over soon ..when the next sucker is up to bat in this understaffed,overworked career of ours.

[ProperlySeasoned]

Your license is fine. Are the medications with similar packaging stored next to each other? If they are, one simple solution would be to seperate them. Also, bar code scanning could have helped in this situation.

[LCCnurse123]

You reported this situation which was the best thing you could possibly do. As long as the patient was not harmed and is still living and breathing don't worry. Yes its a incident but the patient is ultimately still safe! and you should not be penalized for it depending on the facility they will make note of it but don't stress.

[elijahvegas, ASN, RN, EMT-P]

do you not have an electronic system? im a bit confused at how you were able to scan a med that wasn't on the pts eMAR. mine wont let me proceed unless i scan the right med

[chacha82, ADN, BSN]

This is part of where I am stumped though. There were definitely elements of fatigue, distraction, rushing to give the med tech her space back, having two different medications with very similar packaging, etc. But at the end of the day I know this was simply a human error that I committed because those elements I described above happen every shift and I don't make a mistake like the one I posted about here.

Use this as a chance to review med dispense with your colleagues and make it an interdisciplinary thing. You probably meant this in a nice way, but don't feel like you have to rush for the med tech. We ALL have a job to do and you pulling the right meds is more important than the med tech "finishing" at a certain time (I was a tech so no disrespect meant, I just mean every part of the process counts). Medications in similar packaging is a med error waiting to happen. Also if you are pulling meds and someone comes up wanting a diet coke and ice, let them know you are actively dispensing meds and will be able to help them in a few minutes. Where I went to school there was giant red tape around med dispense and signs to not interrupt the nurse.

[kbrn2002, ADN, RN]

I have been looking to try and find this information, but I have not been able to locate it. Is there a way to find this specific information?

Every BON has a section somewhere that lists all disciplinary actions. They are a matter of public record though that doesn't mean your state's BON makes it easy to find. If you are curious just look around on your BON website, the link to it is there somewhere.

I can say with complete confidence though that you are fine. A simple med error is not something that would even be reported to the BON unless it became a pattern of errors or if there was harm to the patient as a direct cause of the med error. Even then I've never seen a disciplinary case where a nurses license was affected by one med error. The vast majority of licensing issues are because of drug diversion followed by falsifying documentation in a distant second place.