Med error...need to vent!/suppoet

Nurses General Nursing

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I'm on orientation currently at a facility. A patient came in with ofloxacin drops that were to go in both eyes. The medication came from the pharmacy at the hospital, including its little zip block bag with the medication name and directions. And was also administered at the hospital, and sent with the patient on admission a few days ago. After giving the eye drops, I noticed it was filled for the ear drops :( doctor notified, refresh drops and new medication ordered. I just feel awful. Patient denied any eye pain/irritation fortunately. Such a breakdown in a system but I feel terrible I didn't catch it until after it was given. Family was not informed as I was told it can be more distressing if no poor outcome resulted. I don't know what I'm really asking, just venting.

We've all made errors! I would check your facility's policy about using outside pharmacies' meds. At facilities where I've worked, if a medication comes from an outside pharmacy/hospital, the current facility's pharmacy has to double check it prior to administration. That could have possibly prevented this error.

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I. Can. Not.

It's like these stories you hear of people putting tube feeds through an IV. Just.... how? Why? How is this is a mistake you make?

YES! A handful of years ago this occurred at a hospital in Oakland, CA. As a result, my hospital had the tube feeding vendors give an in-service on using their products correctly. We were all dumbfounded on how this error would occur.

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Medication errors are the worst! After years of zero errors, I started a new job and administered a psych med, just after the pt swallowed it, they said: "I take this every night, not in the morning". Of course I immediately started have palpitations! The order was written for "0800" in the MAR (not a new order). But when I looked in the chart, it was scheduled for 2000. My coworker who transcribed the order (awhile ago) said the reason was "everyone's confused with military time", "It's your job to go back and read all the orders before given the meds". WHAT?!

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Specializes in Flight, ER, Transport, ICU/Critical Care.
Like the other members said, clh8987, a mistake was made, you caught it, followed through appropriately and no harm came to the patient. Good job!

Unlike this situation:

attachment.php?attachmentid=27834&stc=1

Can you imagine how painful an IM 30ml injection of MOM must have been for the patient?

That is badness.

Holy Mother of Dog.

*~*~*~*~*~*~*~*~*~*

OP, live, learn & carry on.

This experience will make you a better nurse going forward. Guaranteed.

Onward.

:angel:

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Specializes in Gerontology, Med surg, Home Health.

Really? Not to notify the family is wrong. And...we've all made mistakes.

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Specializes in nurseline,med surg, PD.

Family should have been notified.

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I can't imagine 30 cc IM MOM. I hope someone corrected the student! And how did that pt fare p that shot?

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Specializes in Adult MICU/SICU.

I routinely call in telephone order Rx's for the on call provider when they're too busy (and it's not a controlled substance) - on several occasions when calling in a Rx antibiotic eye gtt the pharmacist has stated that the eye gtt version of that particular medication was not available/in stock, but the antibiotic ear gtt version could substituted instead. I always ask what the difference is between the eye and ear gtt preparations? The pharmacist so far has always stated "None".

I could be wrong (it wouldn't be the first or last time) but unless it specifically states "Not for use in eye" then this may not even have been a Rx med error at all.

I bet if you called the inpatient pharmacy and discussed this specific situation with a pharmacist you may find that this is the case, and you have been worrying and beating yourself up for nothing.

I'm so sorry for the anxiety and distress you've suffered over this. It can be frightening to think you've made a medication error, but very few nurses will retire with a spotless medication error record under their belt.

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I accidentally put Debrox in my own eye last month. It hurt like crazy, but it didn't even get red.

It could have been worse, but lesson learned.

I've done that. SO NOT FUN!

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