Med error~Hard to explain on paper!

[jaxnRN]

i made a medication error. i was filling out the form and need some input.

working in a ltc on monday, and the nurse who was reporting off to me and counting narcs mentioned that it was "patch day". which means that in the hall we were on it is the day to change the duragesic patches on residents. (actually two residents).

well, i signed a patch out for each resident so that i could apply them that morning.

this is a very busy hall and a lot of acuities for ltc. i had one resident in severe distress and several others with acute serious needs. not that it is an excuse, i am just trying to paint the picture in the real world. the nurse that told me that it was "patch day" is an excellent nurse and i can never remember her making errors herself.

so, i applied the patches and then went to put them on the medication administration record. i then read that it is not "patch day". patch day was yesterday. :doh:

so, in reality i had removed the existing duragesic patch and replaced it with a new in 24 hours instead of 72 hours as ordered.

the order for the patch reads: duragesic patch 25mcg q72h as needed!!!!

first of all, we never write these patches as needed. so, at least looking back at the order i did catch this pharmacy error. but, still changed it too early.

anyway, the duragesic patch is a continuous release. this error would not be considered "double dosing", right? and when the patches fall off or will not stay adhered for whatever reason we replace with a new patch. no med error occurence has ever been written up for that!

my don isn't upset with me at all. i am upset with me. when i worked with home health and hospice if the patches fell off we were to tell our clients to apply another. i am just so frustrated that i could have been so busy that i made this error.

when filling out the medication occurence report i tried to logically think about how this is an error. of course, it was put on too early. but that doesn't increase the dose. plus, the pharmacy and the physician's order for the month actually states to use as needed!!! this resident is never in pain so either the duragesic has done its job or we need to decrease the dose. there is no documentation that the pain patch is needed.

so, it's actually a good thing that this happened. it definitely made me slow down and it revealed the pharmacy/md error for prn dosing. for a couple of years the dose was q72h routine. and the med was listed on the medication administration record under the routine meds when it even reads "as needed".

:zzzzz if you are still reading and following me, my question is this: how would you word this error? there were no adverse effects. does changing this patch in 24h actually give a med dose error????

i've been working way too many long hours. :stone:smilecoffeecup:

thanks for any input and ideas. sorry this was soooooooo long!:redbeathe: i just feel really stupid for making such a dumb mistake.

:urgycld:

[Farmer Jane]

It is an error, simply because the change is supposed to happen q 72 but it happened q 24. The vast majority of errors do not harm the patient. Every nurse makes mistakes--it's okay.

[RNBelle]

I have had my own experience of having a med error that was one of those odd situations. So I understand how you are feeling. The patient was not harmed and that is the most important thing. You will learn from it and take the lesson with you.

[jaxnRN]

yes, in my 18th year of being an rn i am still so hard on myself. i was "raised" by a very, very, very serious surgeon who made me the nurse i am today.

details. details. details. i guess it just seems like a huge deal to me and even my don told me "don't worry about, everyone makes errors. i know you are an excellent nurse". it's just like "ugh!" how dumb of me!

it was clearly my fault. thank god it didn't hurt anyone. i have worked some high stress jobs that required fast thinking and acting and i guess i should be thankful that i haven't done anything worse than this. yet.... :)

thanks you guys. we all need to have each other's backs!

[MadisonsMomRN, BSN, RN]

You know the good thing is that you didn't try to hide it. Not saying that you ever would but I have seen nurses try to hide or not report med errors.

We are human... it's ok!

[JaneyW]

This mistake could have been avoided by using the basic med rights. You always have to check the MAR first. We all make mistakes no matter how good of nurses we are. You cannot just take report and not double check it. I am in a LTC with students right now and I understand how hectic it is. Always check the chart/MAR to make sure the information is accurate.

Don't beat yourself up. It is hard not to, but your patients need you to be confident and there for them. I have great respect for you LTC people.

[jaxnRN]

Oh yes! I know too well of the error that I made. That's probably my point. I KNOW better!

I absolutely LOVE having students and orientees. When I had nursing students with me in Home Health and Hospice I think I tried to teach TOO much!

I was lucky to have worked for a physician for many years who was an awesome teacher to his staff. He would explain anything to us and share unusual occurences in the OR.

Experience is the best teacher. And that takes time!!!!! In 17 years of nursing, I can honestly say I learn at LEAST one new thing every day!!!!

And if I don't know the right answer, I always look it up! My boss calls me a walking encyclopedia! But this is also a great place to come for info. Love this site!

[rn/writer, RN]

I understand your being upset with yourself, but beyond a certain point, you risk losing your focus and becoming prone to new and different mistakes.

No, there was no dosing error. The amount of medication released was not altered by changing the patches early. The only negative consequence was that 48 hours of medication was discarded in the patches that were still good. If that's the worst thing you ever do, you're golden.

Don't beat yourself up over this. The good kind of pride in your dedication and safe practice can morph into a not-so-good kind of pride if you scold yourself for being "above that sort of thing." The truth is that we are all capable of making a rushed or skewed decision.

Please, take away a lesson learned (and shared here for the benefit of many), and allow yourself the freedom to move on unhindered.

Thank you for your honesty.

[stephlucasrn2008]

Yes, a med error. I know this never helps but YOU DIDN'T DO THE PATIENT HARM. Things happen and often nurses (including myself0 are too hard on themselves. Last week I was interrupted while preparing to hang an antibiotic. Never primed the tubing, just threw it on the pump. THANK GOD THOSE SUCKERS SENSE AIR!!! I think what you did is very minor! At least you took the other patches off!

[uscstu4lfe]

life goes on. don't sweat it

[MadisonsMomRN, BSN, RN]

I agree with the others. Don't beat yourself up. I think we all have made errors. I am a lot like you... I just keep kicking myself in the butt.

Long term care is a tough job. You are doing the best that you can! :)

[ann945n, RN]

No one was hurt that is the main thing. Try not to be too hard on yourself, you caught the mistake and reported it. Thats says alot, some people dont even go that far. Dont be too hard on yourself, though I know you will be, We ALL make mistakes including myself!