Has anyone made a medication error and *not* get fired for it?

[pinkiepieRN]

I screwed up tonight, plain and simple. I had meds pulled for two patients and started giving meds to one patient. I pulled the pills in their packages out of the cup and told him each med and their dosage. The second after he put the cup to his lips, an "oh ****" comes out from under my breath. I realized that what I had given him was intended for the other patient and that I had made an error. I walked back to the nursing station, told another nurse, told the charge nurse, called the doc, got an order for Benadryl to prevent any undue reactions, however unlikely, filled out an occurrence report, documented in the chart (without saying it was an error) and made it through the rest of my shift. Everyone was telling me that it was okay and I did the right thing, but I'm terrified. I'm thinking about calling my supervisor in the morning and admitting my screw-up before she gets the wrong idea. Is this nuts?

[Jory, MSN, APRN, CNM]

I have made two medication errors...one was due to inexperience and one was when I was in a hurry and skipped one of my "checks". Neither was serious, I never even got wrote up for them. However, after the second one you can bet your bottom dollar I was 200x more careful.

[psu_213, BSN, RN]

I know of one nurse who was fired for "a" med error...she basically made one or two per day. I also know nurses who have made "big" med errors...the owned up to them right away and they were not fired.

[sharpeimom]

One meds error I made as an inexperienced nurse was avoidable but the room assignment should never have been made in the first place, according to the NM.

Bed 1 - Mary Smith

Bed 2 - Mary Smith

The first patient was AA and the second was Caucasian. When I made my error, Mrs. Smith, in bed 1, was out of the room.

[psu_213, BSN, RN]

sharpeimom said:

One meds error I made as an inexperienced nurse was avoidable but the room assignment should never have been made in the first place, according to the NM.

Bed 1 - Mary Smith

Bed 2 - Mary Smith

The first patient was AA and the second was Caucasian. When I made my error, Mrs. Smith, in bed 1, was out of the room.

If anyone should be fired, it is the person who made that assignment....

(OK, not fired, but this really has to fall on that person)

[skylark, BSN, RN]

You did the right thing by owning up and fixing it straight away and that will count in your favor.

None of us are perfect and I'm willing to bet there isn't a nurse here who hasn't made an error at least once.

Mine was back in 1993, 8 year old kid after surgery, morphine was charted as 5mg PO (or 2.5mg IV).

Yup you guessed it, I never saw the second dose until I started to give 5mg IV.

Told the doc straight away, he said to do 15 minute vitals for one hour and don't worry : )

[skylark, BSN, RN]

Oh and I had a 'Mary Smith' situation once too!

They were actually sisters in law, were married to twin brothers.

Same name, similar DOB, same year and month, and similar address, same road just different numbers.

And in adjecent rooms on the same floor.

Both had had gynae surgery with the same surgical team.

As far as I know we didn't make any errors, but it was a worrying time : )

I know I was relieved when they went home:wacky:

[RN58186]

sharpeimom said:

One meds error I made as an inexperienced nurse was avoidable but the room assignment should never have been made in the first place, according to the NM.

Bed 1 - Mary Smith

Bed 2 - Mary Smith

The first patient was AA and the second was Caucasian. When I made my error, Mrs. Smith, in bed 1, was out of the room.

Many years ago we had two pts on our floor with identical names (including middle name if you can believe it). They were in the same four bed room, and they were both blind diabetics on peritoneal dialysis. Talk about an error waiting to happen. We had requested that one be moved, but were told if we did all our checks properly an error wouldn't happen. Finally one of the pts requested a move to a different room so they were separated. It was actually kind of scary.

[BrandonLPN, LPN]

Any nurse who says she's never made a med error is either lying or dangerously unobservant of her own practice.

[Sugarcoma, RN]

Medication errors never happen in a vacuum. There are usually multiple "system" issues which are a contributing cause to the error. Even in the case of giving the wrong medications to the wrong patient, I imagine there were some system issues that helped to contribute. High ratios, high acuity, short staffed, multiple interruptions, etc. As nurses there are so many demands on our time, it is truly astonishing that errors do not occur more frequently.

I have given the wrong type of insulin to a patient and was not fired. I also gave a double dose of a med to a patient and he did suffer hallucinations because of it. It showed up twice on my MAR right next to each other and was programmed into the pyxis. I felt horrible about that one. Both my employer and the patient and his wife were extremely forgiving. The patient even asked for me back the next day. I was stunned! I even asked him why and he replied "your a human and you will make mistakes, I have made my fair share."

I think it shows a true concern for your patient's well being that you alerted both your charge and the doctor to this issue. Medication errors are really easy to cover up. It definitely shakes your confidence and causes a lot of anxiety. You can feel good in knowing that you acted in the best interest of your patient's. I would be absolutely shocked if you were fired for this error.

[DoGoodThenGo]

dolcebellaluna said:

I screwed up tonight, plain and simple. I had meds pulled for two patients and started giving meds to one patient. I pulled the pills in their packages out of the cup and told him each med and their dosage. The second after he put the cup to his lips, an "oh ****" comes out from under my breath. I realized that what I had given him was intended for the other patient and that I had made an error. I walked back to the nursing station, told another nurse, told the charge nurse, called the doc, got an order for Benadryl to prevent any undue reactions, however unlikely, filled out an occurance report, documented in the chart (without saying it was an error) and made it through the rest of my shift. Everyone was telling me that it was okay and I did the right thing, but I'm terrified. I'm thinking about calling my supervisor in the morning and admitting my screw-up before she gets the wrong idea. Is this nuts?

Not to point out the obvious, but if you've already told the charge nurse and pretty much everyone else on duty at the time, *now* you are worried about telling your supervisor?

Being as all that may what is the protocol for self reporting med errors? Is telling the charge enough and she will take things from there, or are you required to speak to someone else above her yourself?

Med errors happen, and many if not most in nursing supervisory or administration roles understand that, however dishonesty is another matter. Think you'll find that nursing is like most other forms of employment; errors can but rarely are the cause of termination. There is usually a back story and the occurance provides *cover* for termination or whatever action is going to be taken.

Thing to remember is this: mistakes do happen, but they musn't happen too often.

[BSNbeauty, BSN, RN]

Thankfully, I have not been fired for a med error. I think it depends whether or not the patient has an adverse reaction.

[itsnowornever, BSN, RN]

I gave ampicillin instead of ancef (we stock amp and give it all the time, habit and not paying attention caused the error). I called the doctor, told my preceptor And the doctor just said to change the order, ampicillin was just as good. I will tell you, I triple check EVERYTHING now.

When we were short Nubian we had 10mg stocked instead of our usual 20. Pharmacy filled our stock back with 20 and didn't mark ANYTHING or tell ANYONE. I Caught the error on count and spent the next 30 min highlighting the back and front labels of all the 20mg so no one would make a mistake- who knows which patients received 40 instead of 20...that was a dangerous mistake waiting to happen.

Posting from my phone, ease forgive my fat thumbs! :)