I Made a Medication Error

nursedawn67, LPN · Sep 26, 2004

Congratulations! You are human! The best things is you recognized the mistake and owned up to it immediately. I have to congratulate you on your honesty and bravery..you will make a great nurse!

directcare4me · Sep 26, 2004

I have to echo what everyone else has said. There's no one living who has never made a mistake, only those without the courage to admit it. You were brave, professional, and put the patient's best interests above your own fear at making it known that you made an error. You will be a very good nurse; in fact, you are already.

Now, go forth and don't lose your confidence. Enjoy yourself. Don't continue to beat yourself up. Just be glad you've had this "lesson", and gotten it over with.

Maggie in NC · Sep 26, 2004

I am glad you posted this. We all learned something from it. You're brave, honest, and doing the right thing even in a bad situation. It says alot about your character! Thank you for teaching me to verify, verify, verify!!!

Chin up, you're better than you think you are. We all just got to witness that by your post :)

PJMommy · Sep 27, 2004

I also want to echo what everyone else is saying. The scariest nurses I work with are the ones who are absolutely positive they would *never* make a mistake. Sigh...

I made a med error about 4 months out of school and on the job. I felt so stupid. Pt c/o pain so I go look at what prn's I have to give...sweet, I can give morphine. I check...yep, morphine hasn't been given for a while and I'm okay to give again. Go tell pt, "I'm getting you morphine." Pt says, "I don't want morphine, it makes me sick. Can I have something else?" I go look...yep, pt can have Tylenol c codeine. Go get and give the T3's but I didn't check when pt had last had it...uh, try 30 minutes ago (right before I came on shift and nurse didn't mention giving it in report). I felt so stupid when I called the doc and admitted my error. Had to do an incident report, etc. Sigh... fortunately, pt was fine.

The moral of the story...the "right time" also means checking when the med was LAST given -- especially for PRN meds.

Like you, I'll never make that mistake again. :) Tough, embarrassing - yes. A learning experience - definitely.

LauraLou · Sep 27, 2004

I always take the MAR into the room, but I also write the room number on the med, if possible. For example, Percocet comes in those individual bubble packages (if you know what I mean) and I write the room number on the back. We rarely give drugs that aren't individually packaged, so there is usually a way to write on the medication package. If not, I write the room number on a piece of tape and attach it to medicine cup or whatever the med is in. It really helps, especially when you have meds for more than one patient.

I think you are going to make a great nurse!

CarVsTree · Sep 27, 2004

Thanks everyone for your encouraging words. I had a much better clinical day today - no med errors :)

I spoke with my clinical instructor about the error, how it happened, how I now handle things differently, etc. She admitted that she was in error, not requiring me to chack the ID.

rn undisclosed name · Sep 28, 2004

I'm sorry that happened to you but don't beat yourself up over it. Just look at the good that no harm was done. I'll bet the only reason this happened was that you were so nervous about passing meds for the first time and if your clinicals are anything like mine you also don't get too much sleep either.

But, that nurse is right - you'll never make the same mistake again.

Kelly

hotrodrn · Sep 28, 2004

I am kicking myself. Fortunately, no harm came to the patient.
This is my first time passing meds this semester (we usually only get to pass 1-2 times per course) and I forgot about the 5 rights. Apparently my clinical instructor did also. Anyway here it goes...
Went to med cart and looked up my patient to give meds (had 2 pts but only passing meds on one). Verified that I had the right meds, right dose, right route. Left MAR on cart (had no idea you're supposed to bring MAR into room w/you but that's a whole other story). Brought room 916's meds into 915's room. Told pt (never asked for his name, never addressed him by name) what meds I was giving him (Percocet & a Colace). He took them. Now is where I'm in a total panic and don't remember exactly... Clinical instructor walks off and somehow I realize I just gave 916's meds to the guy in 915. I immediately tell the primary nurse. His doc is sitting at the nurse's station. Primary tells MD (I made sure to look him in the eye so that he knew I wasn't skanking away from my stupid error) that pt. received percocet & colace (fortunately this pt also happened to be constpated :uhoh21: ) and he looked up and said oh that's o.k. So no big deal, no harm done... But... I felt like a total idiot and slug. I began questioning why I (who can be a total flake, space cadet at times) think I can be a nurse where an error can cost someone their life.
I told my CI what happened and after her shock and disbelief, she told me that it was partly her fault because she should have had me verify the pt. I went back and talked to the primary nurse (I was pretty shaken up by what I did). She told me that she ALWAYS brings the MAR in with her and has the pt. state their name and birthday and/or verifies pts. name & birthday on their ID bracelet. She does this with every pt. every time. She told me, "I'll bet you'll never make this error again." I know she's right that it was actually a good lesson to learn as no harm came to the pt.
I didn't even want to post this because I feel ashamed of being such an idiot, but I know others can benefit from my experience. I just feel like when I'm doing meds, I'm so focused on the med itself that I lose site of the pt. I will NEVER give any drug to any pt. (even if its the 5th med I've brought into the pt. that day) w/o first IDing the pt.
I just thank God the pt. wasn't harmed. I cannot even imagine how that would feel.

Dont be to hard on yourself. It was a small mistake. We all make mistakes. No one is perfect. Like one day when I was an Associate degree nurse I and one other nurse went to give a blood transfusion. She was the primary monitering it. I just stuck the IV in and prepared the lines. Well I checked the blood. But old goofball just decided she didnt need to double check it and signed off on the second nurses signature. Thank god the patient didnt have an allergic reaction to the blood otherwise we would have been up a creek since there was two of us on the unit at the time.

Rod RN:angryfire

Twright49015 · Sep 28, 2004

Hello Sue

I currently work in a long term facility on the assisted living floor, I am responsible for passing meds to 24 residents. In the 3 years that I have held this position I have made the same med error twice. I have one resident that takes xanax and one resident that takes ativan. While doing the 6 am med pass I accidently twice mind you, switched the cups, I gave the one that gets xanax, the ativan, and vice versa. Yes at first I about spaazed, I told my charge nurse, had to call the Dr. and call the family, yeah that was exciting!!!!!!! And in the assisted living facility the residents do not have arm bands, nor do we have pics in the med book of the residents. So yes mistakes can happen to the best of us, but we learn from our mistakes, and move on. Let me tell you I learned after twice, and have never made that error again... But see you are not the only one, and don't be so hard on yourself....afterall, error is human and we are all human.

Theresa