Guilt About A Med Error

[Katie Hill]

I believe I made a med error a little more than 2 months ago(LTC). Our system does not have scanning equipment so it's all self-check based. I gave the wrong medication to the wrong patient. They were meds that were relevant to the patient's diagnosis, but he was not prescribed them. I did not say anything, just monitored the patient, and went on with life. He died five days later. I do not believe the meds were lethal, and everyone at my facility believes he choked during the night. He had been having chronic difficulties with coughing and he had excessive secretions. During the night we were often having to sit him up to help him clear his lungs. Any advice for dealing with my horrendous guilt welcome.... According to his charts the day of his death, he was having a really good day...even walking which he rarely did. He died that night.

[Katie Hill]

P.S. meds in question.... donepezil and escitalopram. The patient was 92

[Lynker, LPN]

Katie, you made a tiny medication error. Your error did not cause him to pass away. Unless he was deathly allergic to them, there's no way your error could have caused it. Both meds you gave take a few weeks to start "working" in the body, as they are considered maintenance drugs. Even if he was allergic, you would have seen his reaction within a half hour to hours later (Which you didn't see).

I believe this was purely a coincidence.

If I may, I was also training at my first job in LTC, and I gave the wrong meds...it was an entire bedtime med pass to the wrong patient. I was thinking too fast, and gave the entire med pass to a different patient in an entirely different patient room. I let my trainer know, and we called the doctor together. No harm was done.

Don't feel too bad. Just remember it as an opportunity to grow and of course, make sure you tell someone next time. It happens. We're all human!

❤️

[CrunchRN, ADN, RN]

No way those impacted the eventual death.

[Davey Do]

Not experiencing self-deprecating feelings after an event such as this would be more cause for alarm. Especially when we know that we didn't follow the rules to T and fudged on the facts.

I made numerous med errors over the years and self-reported just about all of them. For example, if the med were a controlled substance, there was no way I was not going to follow protocol to the Nth degree.

My last med error was when I administered 50 mg instead of 25mg of Trazadone PRN insomnia to a patient. Oh well. No big deal.

Acetylcholinesterase inhibitors do very little therapeutically anyway when administered as RX. They inhibit the production of acetylcholine in the brain which theoretically slows the memory loss process. Untoward reactions are extremely rare.

SSRIs theoretically relieve depression by keeping the synapsis high in serotonin, a naturally occurring neurotransmitter. The most prevalent side effect is GI upset.

So, I agree with Lynker and Crunch in that the patient's death was in no way directly related to the administration either of these meds.

The best thing we can do after feeling as though we've wronged is to admit it to ourselves, another human being, and to our higher power the exact nature of our wrongs. You've done the first two, if not all three, Katie, so it's time to learn from this and move on.

The best to you.

[raebabelvn, LVN]

The day my grandfather passed was one of his best days. He was happy, minimal complaints, minimal pain... it was amazing. But, he laid down to take a nap and had a heart attack in his sleep. Sometimes having a good day prior to death seems to be a thing.

[Davey Do]

18 hours ago, raebabelvn said:

Sometimes having a good day prior to death seems to be a thing.

It's called a "Swan Song Effect" in reference to Tchaikovsky's classic ballet, Swan Lake, where the swan does its most beautiful dance before it dies.

Seen it many times: A patient will rally, look & feel good, then die.

One theory attributed to this phenomenon is the exponential release of neurotransmitters in the brain as the body's last-ditch effort to prolong life.

[CharleeFoxtrot, BSN, RN]

Good advice above.

OP if you are posting under your real name you may consider asking our lovely admins to help you change to a pseudonym. The internet is forever, just my 2 cents worth. 

[JKL33]

It is possible that at least some of your guilt is because you did not do what you knew you should have done when you recognized your error.

And you know what? This is strictly my opinion but I say it is okay to learn from something like that and then forgive yourself and....let it go.

Just like people can learn a lesson of "I might give the wrong dose if I don't carefully check 5 Rights," we can also learn moral/ethical lessons like, "I don't like how I feel right right now, so next time I will follow the proper procedures even if I'm scared/there is a problem."

Life is about learning all kinds of things about the world and about ourselves. Please forgive yourself and you will be able to move forward as a stronger person. ? ??

 

[JBMmom, MSN, NP]

You made a mistake, we all make them. And you probably feel worse about it because you didn't tell someone when you realized. Been there, done that. I lied once about a milk of magnesia/ maalox mix up (one scheduled, one PRN, and I accidentally gave the PRN). I was brand new on orientation, things already weren't going well, and I panicked. In the end the lying was worse than the med error. The meds you gave DID NOT cause your patient's death, as others have already pointed out, but you're still fixated on it because you didn't tell someone. Let it go, learn your lesson and know that you didn't cause any harm.