S. O. S.

SICU Queen · Mar 4, 2002

((((((BIG HUG))))))

Honey, we've ALL made med, and other, errors. The many posts above mine have shown that. Don't let it get you too down. I've given Ativan instead of alprazolam. Not a biggie, but still an error. And that's only ONE that comes to mind. I've made a few others, especially right after graduation. Nothing major, but still enough to make me feel like an idiot and wonder if I'd chosen the right profession.

Once, right after graduation, I was working on a rehab unit, and one of my elderly patients was very confused. I BELIEVED him when he promised me he wouldn't get out of bed if I took off his posey. I went to give him some meds and couldn't find him. AN HOUR later my co-worker and I found him down in the ditch next to the hospital. He said he was fishing (nary a pole, or fish, in sight). To top it all off, he was naked. I thought I was going to have a heart attack and DIE right then. Now I just have to laugh. Live and learn.

I've worked with a nurse who mistakenly set her pump at 800 cc/hr to run her Heparin in (thinking of 800 UNITS/hour, which would be either 8 or 16 cc/hr depending on your concentration). The patient got 250cc of heparin in just a very few minutes. My friend was HYSTERICAL! But the heparin, being what it is, was gone rather quickly and the patient suffered no ill effects. But it still scared the crap out of her! This friend of mine had been nursing for YEARS in ICU and was having a really bad night. Just goes to show it can happen to ANYONE.

I also worked in a hospital where a new RN gave 150 units of regular insulin SQ instead of the 15 that was ordered. She mistook the "u" for a "0". The patient died and the nurse went back for "pharmacological remediation".

SO, keep your errors in perspective, learn from them, and remember you're human.

hpyrn · Mar 4, 2002

I mad it al the way through nursing school without a med error. unlike many of my fellow students. my last rotation was critical care and it was the last week of clinicals before graduation, and my instructor was Corella Deville, my pt. had a primary line runnign with about 4 piggy backs. I hung something programmed the machin and walked away knowing I had done something wrong. when i figured it out i grabbed my preceptor and brought her in the room and explained to her what had happened,she corrected it and told me not to worry about it, I said I am going to call the res. on call, and tell my instructor, she said there is no harm done, dont worry about it. I went ahead and called the doc and hunted down my instructor and told her. She looked at me and said I was outside the door listening when you were telling your preceptor and had you not come to me today you would have been out of school. WOW---- we all make mistakes, just owe up to them, learn from them and go on. We are human, we make mistakes. xoxoxoxo

jherman · Mar 4, 2002

:rolleyes:

I am a critical care RN and have been working in Quality Improvement for a while now. Medication errors are a focus nationwide because they are the most common error in medicine.

A medication error usually doesn't happen because one person or process failed. There are usually several failures along the was starting with how the prescription was written (legibility, correct dosing) to the nurse who actually gives the meds and the 5 rights. Unfortunately nursing usually gets the blame because we are the last protection to the patient. (We are on the "sharp end" of medical care. Administration is on the "blunt end" everyone else is somewhere in between)In our hospital there are 24 steps from the time an order is written to when it is given to the patient, and a mistake can happen at any of those steps.

So the message is, it's not all your fault, there were several failures along the way. If you want to do something, work on changing the SYSTEM- ie. computerized order entry, (with checks on dosing, allergies, etc), robotic filling of rx's. barcoding on the patient the pill etc., education and reinforcement to all involved in the medication process.

I would love for you to take care of me because you are consciencious and you care.

lever5 · Mar 7, 2002

Have all of your learned not to say, "I'll never do that", ? I will try to learn from each of you, so that I can avoid making these mistakes. But, sadly I have had a lot of close calls with similar circumstances. The best thing you can do is listen to those little warning gremlins. Treat the narc. cart as if it is an enemy trying to trick you. My tolerance for insulin stops at 10 u. Anything higher I have to see written in the chart. Anything higher than than 15 u I check with the patient or sometimes old med records. 60u if not comfirmed by patient or old records would get a call to the doctor. All of this will sometimes still not be enough to make me fell comfortable. Oh, yhea, the big bo-boo, switching the lines for heparin and nitro. or something else. A lot of nurses tag their lines, good idea. Our profession should have coined the line,"BE CAREFUL OUT THERE!"

kids · Mar 7, 2002

My first med error was (thankfully) insignificant ...

I gave the wrong med to the wrong patient at the wrong time:

Digoxin 0.125 mg at 0800 to a patient that was supposed to get 0.25mg at 1200.

I worked in a SNF and paniced...did the med error report and everything. Thought I would be fired and my days as a nurse were over, they would take my brand new license.

Notified the Doc, his response..."and your point is?"

Heather56 · Mar 8, 2002

Isn't it funny how we tear ourselves up over mistakes but when we have those great shifts, you know, catch that slight change in a patient's condition that saves the patient's life; manage to settle the elderly, confused patient that no-one else has been able to; even get a smile out of patient who has been having a hard time, we neglect to give ourselves that well deserved pat on the back. Everyone makes mistakes but we also do alot of great things so pats on the back for all of you.

RN-PA, RN · Mar 8, 2002

Heather,

Well said-- I agree totally!

I forgot to mention in my previous post about my own error that our hospital has recently institued a non-punitive med error reporting policy.

A while back, a coworker made a med error and wrote up an incident report, dreading the consequences. However, a week or so later, she found a note in her mailbox THANKING her for reporting her med error, and there was a card for a free beverage of her choice in the cafeteria :eek: I remember reading that more hospitals are instituting this policy to encourage people to report errors and to better track problems in the system.

StirLady · Mar 12, 2002

Congratulations! You have just officially joined the human race and the nursing Profession. You have not been tried in this profession until you have been tried by fire. The trick is to only get crispy around the edges.

We have all been in your shoes. And I have more news for you, this was most likely not the last med error you will make. You won't make the same one, but you will have a new opportunity to beat yourself up again. BEAT GENTLY. You will need that energy to expended to help another patient.

I suggest you use your computer and a forms program (there are some very good, and cheap ones out there) to devise a personal worksheet for yourself. If you have the potential to have a lot of deaths in your unit one side or the other make some "Cheat Sheet" tables with check-offs to help you finish all documentation needed. But never delete that page, just save it, you may be able to help another nurse by giving her the tool to keep from making that mistake. I am of course referring to the missed step in documentation with your death.

With you med error, I suggest that you get just a little/slightly aggressive with the people who have your charts and MAR's when you need them to do your job. Sometimes I feel like I have to look at an order 3-4 times to insure in my own mind that I do see it, as well as all the other R's involved in the med chain. I have called Dr's for clarifications of orders, one that sticks out started printing because I told him "honestly, DR, I can't read your writing". As for the other nurse noting the order, ask for help, but never assume he/she will do it. Also, all of us must remember that sometimes you have to pass something on to the next shift, because most facilities FROWN on OT.

CHIN UP, YOU WILL SURVIVE THIS AND ALL TRIALS BY FIRE.

Stirlady.