Med error :(

Nurses General Nursing

Published

So I have a resident that is on primodine 250 mg : give 1 tab TID (6 am, 12 p, 8p). The pills were in half. Her order just recently changed to ONE whole tab TID. So I was suppose to give two half tabs, so the last few days. I was only giving half of the recommended dose at 6 am. The correct dose was given today. I feel so guilty. The resident is completely fine, no changes in condition. I asked the first shift nurse what to do and she said it was alright. The mistake was made over a day ago. I'm not sure what to do. I'm going to talk to my supervisor today.

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I probably wouldn't talk to your supervisor. Do you have a reporting system at your hospital? I would just file an incident report and reflect how to improve in the future (ie read orders more clearly, have whoever checks orders highlight the number of pills etc).

Everyone here has made mistakes and the majority of us get that same, sinking, sick feeling when you do. Take a deep breath, forgive yourself for being human, and try not to make the same mistake again

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I work in long term care. We just have a med error report :/

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Specializes in Cardio-Pulmonary; Med-Surg; Private Duty.

The DOSE should be on the MAR, not the number of tablets.

That way, if the patient/resident is supposed to receive 250mg and the supplied tablets are 125mg, it's obvious that the patient should receive two tablets to equal 250mg.

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Specializes in All areas of Critical Care, ED, PACU, Pre-Op, BH,.

You are doing the right thing by reporting it to your supervisor. The order on the MAR should have stated the correct dose if it was changed. Hopefully it will be a lesson that will prevent future problems!

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The DOSE should be on the MAR, not the number of tablets.

That way, if the patient/resident is supposed to receive 250mg and the supplied tablets are 125mg, it's obvious that the patient should receive two tablets to equal 250mg.

That's why I'm having a hell of a time trying to figure out how this could even happen. It's obvious the MAR should be fixed, but how it managed to just list the dose as a tablet instead of the actual dose is pretty dangerous.

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