I Made a Medication Error

  1. 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.
    Last edit by CarVsTree on Sep 25, '04
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    About CarVsTree

    Joined: Sep '03; Posts: 1,119; Likes: 113
    RN
    Specialty: 4 year(s) of experience in Trauma ICU, MICU/SICU

    20 Comments

  3. by   angelac1978
    *hugs* don't be so down on yourself! it is a big deal but the patient was not harmed and you know for sure to check the armband from now on! no one is perfect even though schools expect us to be. yes you made a mistake but the important part is that you learn from it. If you went through school without making one mistake, what would you do in the real world when you have 10-12 patients and you make a mistake? that's part of school, learning to deal with it. You did the right thing by reporting it and you did it in a totally mature fashion! Be proud of the way you handled yourself, take from this experience all that you can, and do not doubt yourself! you can do it!

    A
  4. by   cherokeesummer
    Thank you for sharing this. You have a lot of couage to have reacted teh way you did. You told them. You reported it. That is #1. You looked everyone in the eye. You did so great at this. I'm sure that a lot of times this can happen, to an experienced nurse once in awhile too.

    Your sharing this information with me will hopefully keep me on my toes for when we start med admin. We start learning the material this week.

    Thank you again.
  5. by   shyne
    Don't be too hard on yourself, everyone will make some type of mistake in their lives. The good thing is that you've learned from it and admitted that you make a mistake
  6. by   rehab nurse
    the other posters are right you made a mistake, but you also learned from it and will be a better nurse because of it. we all make mistakes as nurses, especially now when there is so little time, and short staffing is an almost daily occurence. i have made that mistake as well, gave wrong meds to a patient, and it happened because i was hurried. i try not to let people hurry me anymore, but it is hard sometimes with doctors rounding, phones ringing (no unit clerk on my shift), families wanting to talk, and mangement pushing the "customer service" ahead of patient safety (tho they'll never admit it).

    you'll be a great nurse!! hugs to you

    h
  7. by   GPatty
    Hey Sue~
    Check out your sig line.....

    {{{HUGS}}}

    I know it feels creepy as heck, but we love you and it's over. Don't dwell and make your self sick over something like that. Learn and move on.
  8. by   allthingsbright
    My instructor keeps telling us that every nurse makes mistakes-and you fessed up to it, recognized exactly what you did wrong, and you are going to be a better nurse for it! Thanks for sharing! I hope I can learn from your experience!
  9. by   maire


    I can't say anything that hasn't already been said. You'll learn from it and be a great nurse!
  10. by   kathy_79
    do not down yourself. as long nothing happened to your patient you are ok. as pt nurse told you, you will never do it again. at my school we are going to pass meds at about three weeks from now. but since the begining we are taught always follow 5 right+1 (1 is documantation). you never know what can happen, if you have right pt, right room, right bed, right med, right route. right time.
    good luck to you,

    remember, even the best people in the world make mistakes!
  11. by   RedSox33RN
    I think you handled it beautifully - not hiding from anyone, admitting readily to it, and accepting responsibility. The hallmarks of a great nurse.

    We all make mistakes. Only one of us is perfect, and He is the one that guides us.
  12. by   Marie_LPN, RN
    You handled it professionally. You spoke up and admitted everything that happened as soon as you realized what happened. And in your post you also said what happened, what the correct actions are to take, and how to prevent this in the future.

    So do not question yourself if you're going to be a good nurse . As a student you did the right thing by following the right steps, and a good nurse would follow those same steps.
  13. by   talaxandra
    I echo what everyone else has said. Mistakes are inevitable - the most important thing is what you learn from them. From this you've not only learned something you'll never forget - to verify the Right Patient - you've also learned that you can face the music, that patients cannot be reliably depended on to safeguard themselves (some will question every panadol, some will without question take whatever you give them), and that making a mistake (even a med error) doesn't mean that there will be a dire outcome.
    Just a question - we now teach the six Rights: patient, drug, time, dose, route and clinical scenario (ie just because it's prescribed doesn't mean you give it). Is this not the case where you're learning? Not a dig, just curious
  14. by   nursedawn67
    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!

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