Made a Med Error and sick over it!

  1. I feel like crap. I made a med error last week. The patient was unharmed and my manager told me that it was a systems error etc. and that it wasn't my fault. I still feel like hell. I missed an AM insulin dose. A patient was handed over as being a non-insulin dependent diabetic and when I reviewed her drug chart (she had 3 of them that were handwritten) I missed the order for insulin. Her blood glucose was fine in the morning but went pretty high later on until I figured out she missed her insulin. :trout:

    Another patient arrested during the AM drug round and I rushed around doing the medications afterward as I was hours behind. I was med nurse and charge for 13 med/surg/ care of the elderly patients with no care assistants and just back on first day after 2 weeks of holiday. The night nurse who handed over to me didn't really know the patients as she only had the patients for the last 2 hours of the night shift in addition to her 13.

    The regular night nurse left in the middle of the night due to sickness so the handover was really incomplete and due to call offs on the day shift as well I ended up on my own and overwhelmed. I called the matron who assured me we were getting another nurse to help out. No one ever should up.

    I also had to hang blood as soon as I got out of report because it should have been given on night shift but wasn't..then straight into the drug round and assessing my patients and answering call bells and toileting and bathing simultaneously.

    Our nurse managers are fighting to get us more staffing and less cutbacks. My nurse manager told me that it was a bad chain of events that lead to this error and that she knows I do well. I think she is partly right. The current situation in our hospital due to government issues is horrendous. But I also know that I should have looked at the drug chart more carefully and double checked no matter what was happening. Feel like crap. I have been an RN for a decade and should be past this stuff. I can't wait to get out of this place.
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    About Martinette

    Joined: Oct '07; Posts: 29; Likes: 43


  3. by   SuesquatchRN
    Good Lord, hanging blood with total care for 13 frail elderly? That requires two here by law, and checks Q15 min!

    It isn't a wonder you missed something.

  4. by   Lorie P.
    Please don't beat yourself up too bad for this. You were way overwhelmed and did the best you could do. Remember you are only one person and can only do so much.
  5. by   Martinette
    I did check the blood with another RN. She had the other assignment of 14 patients on her own at the other side of the ward....and I did the 15 minute check. This was during the drug round, call bells, charge, total care. I know it was my fault and I take responsibility I just want to know why the powers that be get away with this kind of staffing and general BS. Poor staffing is definitely a contributing factor.
  6. by   chocokitten
    wow, what a horrendous patient load with really bad circumastances! That place sounds like a SERIOUS med error just WAITING to happen >_> and I wouldn't hold that med error against you. You did the best you could under the circumstances, and probably better than many other could have!
    congratulate yourself for getting throurgh that terrible with only one (*harmless?) med error
  7. by   James Huffman
    1. You made an error. That's why we call them "accidents."

    2. The patient wasn't harmed.

    3. Your manager said it was a systems error.

    4. Your manager said it wasn't your fault.

    5. Your handover was incomplete.

    6. You were on your own, and you were busy.

    7. You found the mistake and owned up to it.

    So why are you beating yourself up?

    You made a mistake. Learn from it, and go on with your life.
  8. by   jojotoo
    James, very nicely said.
  9. by   Martinette
    I think I am beating myself because when I went back to look at the drug chart the insulin order was obviously prescribed and I don't know how I didn't see it. Yeah live and learn I guess.
  10. by   ElvishDNP
    Honey, if that is the worst thing you do in your nursing career, you are doing REALLY well. The lady who's now my NM once gave someone like 40 more units of reg insulin than they were supposed to get, and she's now the manager! (I won't admit my own mistakes. Far stupider.) You are human, you are going to make mistakes, and thankfully no one was harmed. Hang in there. And continue to clamor for better staffing!!
    Last edit by ElvishDNP on Nov 10, '07
  11. by   steelcityrn
    Got to look at this a a learning experience or in your case a refresher on checking orders well. Don't beat yourself up, had you not caught this, it could have gone on longer.
  12. by   Dalzac
    13 pts with no help!!!!!!!! I am way experienced and seriously doubt I could do that. and you made 1 med error? Hon, you are amazing. And I mean that in a relly good way.
  13. by   Jo Dirt
    Guess what? There will be some med errors that will be your fault. Guess what else? You are a human! It happens!

    I'd love to know the first nurse who has been a nurse more than a year and has never ever made a med error.
  14. by   L19P7N9
    The best thing you did was admitted your mistake. You will be a better nurse for it!