my turn for a stupid mistake

Published Oct 29, 2006

440 Posts

Flipping stupid mistake - very basic, didn't take the time to read properly. Wasn't a horrible mistake, but it was one nonetheless.

What's bothering me is not the mistake itself because it really wasn't serious for this particular patient (although i realize it could be in a different situation), it's the fact that I made it. Palliative care pt needed a breakthrough. She's receiving morphine and medaz by syringe driver, moderate dose. She's had bad reactions to hydromorphone so she was just switched to 0.5 mg of morphine q1h prn. She was very reluctant to take a breakthrough because of her bad reaction to the hydromorphone the day before (frightful, realistic dreams and confusion) She has glio and she's not small. Not unduly large, but not a small lady. I drew up the morphine, gave it to her s/c. When the other nurse came back into the med room, I asked her to sign the wastage. As soon as she paused in front of the narc sheet, I realized something was wrong. I'd given 5 mg instead of the prescribed 0.5 mg.

My coworker, who knew the patient quite well wasn't concerned, felt it would probably do her good, so I followed protocol with the incident report, monitoring the patient, etc. I know she's ok, I know it's absolutely not the worst mistake - I've done a doozy or two in the past 25 years - but it's just the thought that I did it that is bugging me big time. Truly classic, stupid mistake. Grrr.