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?

[PMFB-RN, RN]

SlinkyheadRN said:

Perhaps it's your system that you use. Takes me no more than an hour to chart everything if I'm being slow.

Having worked in a dozen different hospitals in 4 states and two contries I have had to use a number of them. I haven't used all of them so I can't say.

A freind of mine who is co-owner of a tech company in California, and a former RN likes to say that a good computer charting system would allow a nurse to do all of her charting in less than an hour and you should be able to teach anyone how to use it in half an hour. I haven't seen one like that yet.

[THELIVINGWORST, ASN, RN]

Welp. If I scan the wrong wrist band or medication I can't proceed with med pass so I'm able to stop myself from making that med error.

[sistrmoon, BSN, RN]

SlinkyheadRN said:

Welp. If I scan the wrong wrist band or medication I can't proceed with med pass so I'm able to stop myself from making that med error.

Yes and overall, I agree that it reduces med errors.

Mine was a situation with a heparin drip that had been rebolus that was changed to no rebolus in the ED(by a pharmacist helping out in the ED but it wasn't communicated.) There were 2 active orders(rebolus and no rebolus) in the system, the boluses were still active in the PRNs(have to be manually removed rather than just dropping off when the order is changed.) When pt arrived from the ED, all paperwork still said rebolus. I gave a bolus that was clinically indicated by the labwork but the no rebolus order was supposed to be the active order. Patient was fine. It was a huge ordeal and the pharmacists, etc all received education because of it. I suggested a change on the tech side where the boluses automatically drop out of the system if the main order is changed to no rebolus but so far it hasn't happened. You can have some complex systems issues.

[ptrad]

I am a new grad recently working in a very new area. I went from telemetry to intermediate Med/Surge Post Op patients in a different organization and was expected to be completely trained and ready to work independently nights w/in 2 weeks. During the interview process, a complete orientation was discussed, but after hire, I was given 2 weeks on the floor to be up to snuff. True. There were many new learning curves and I committed to being patient with myself while learning about new areas in medicine.

During orientation, which upon my request, exceeded 2 weeks, my preceptors reported med errors to the administration (w/o discussing w/me) and I was recently asked to resign my new position. It would have been ever so helpful to me if the error had been discussed and reviewed instead of reported, so I could learn from my mistake. No one suffered from the error but me.

It was a very unsupportive environment where nurses were rewarded for reporting on each other. Very punitive. I was treated like an unreliable reporter (a liar) throughout the process. Although I learned a lot in this environment (positive & negative), I am glad to move on. The floor was toxic and actually 7 RN's resigned w/in 6 week time frame. Equipment - BP machines, Computers - are inoperable, and light bulbs in the rooms are not replaced. These are things that are easily fixed, however, management continues to blame the hospital for the deficit while punishing the staff for resultant errors due to stress.

I am not sure how I will handle future interviews - not a good fit, nights were hard on me (all true). I am great w/my patients and strive to learn the job, the protocols, the computer systems, in order to give competent service. I strive to support other personnel as well - we need to work as a unit and not eat our young. Eating the young is for hungry male polar bears, not nurses.

I am wondering if other new or experienced nurses have been in this situation and how they handled it. I will not work for this organization again - had I not resigned, my license would have been reported to the state board of nursing. I have interviews coming up and would like to reflect a positive attitude, learn from these mistakes and put a good foot forward w/honesty to my new employer while assuming accountability for my actions. I would like to hear positive suggestions, not critiques of my practice. Seriously, I can beat myself up for my own mistakes and have had some super anxiety moments during the 8 weeks I held this position. I believe we need to encourage and uplift one another, not seek to destroy. Thank you.

[kaylee.]

Isitpossible said:

yup, made med error, informed my DON- she advised me to call physician,call family, and file incident report. that was all, her response, "im sure you'll never make that mistake again."

I noticed you said you called the family. Not sure what your specific circumstances were, but I was just curious if that is pretty normal at everyone's facilities to call the family for a med error.

[suanna]

We have a "non-punitive" "No-Fault" med error policy. It is designed to encourage nurses to report med erors instead if covering them up. It does seem to have worked- our incidence of reporting went up a noticable amount after the policy went into effect. You can still get in some trouble- if it is determined you were so far out of expected policy that you may be clinicaly unsafe- you can get remedial med admin counceling- but that is if, say, you crush a P.O. med and inject it into a IV line- Your problem isn't med administration, it is you may not have enough common sense to work as a nurse.

[suanna]

On the "computer med admin systems" issue; These things are only as helpful as the data they are fed. In todays in-patient world, patients are unstable or they wouldn't be in the hospital. That results in fairly frequent changes in meds and schedules. If the data isn't entered properly to set the patient up to get the expected med, then the patient can go DAYS of WEEKS on the wrong meds before someone notices it. I've seen patients get the wrong med for 2 weeks and people just kept wondering why he was not getting any better and why in the world the doc ordered that med schedule. I've found the errors to be many times more frequent and much more difficult to check and correct with computer med documentation.

[misslindzee]

I wish I had got to this post sooner! I made a medication error TWICE in my career that I caught, and both were the same medication! GO FIGURE! The first time it was change of shift, the previous nurse had already removed the medication and asked me to administer it, I said OK! We had paper charting at this time, and I did not verify the order, nor the patient identifiers. I even explained to the patient what is was given for, and the side effects. She didn't speak up and tell me she's never had kidney issues or anything of the sort. I realized it was meant for the neighbor and stopped her halfway into her Kayexalate. I FELT SO BAD! I went to one of my coworkers and was crying. I notified the doctor first, then notified my charge nurse and after 20 mins or so, I went to the patient, told her what happened and apologized to her. She ended up with diarrhea! Poor thing. Another time 60mL was ordered, and I ended up giving 60grams. I notified the physician and that one fixed his potassium perfectly. Odd timing, the dialysis tech was hours behind. I filled out a form with my charge nurse but it was not a write-up.

[Quinntb]

I gave a medication that I had receive a verbal order for, and chart the the medication under the wrong dosage, the provider entered the wrong dosage what do I do

[cdsavannah59, CNA]

My pharmacy made a medication error years ago, but it was from cashier who gave me the wrong medication. I picked up a prescription for my two year old daughter, who had a ear infection. I had just got home about an hour earlier with the medication and hadn't read the medication label yet to see what was prescribed. I was in the kitchen trying to find the medicine syringe when the phone rang, it was the pharmacy wanting to know if I had given my child that medicine yet, I told them I was just getting it ready now, they replied no don't do that, we gave you the wrong prescription, bring it back to us as soon as possible and pick up the right medication. I don't recall what liquid medicine they gave me and don't even know if it was a similar drug. No harm done, but it taught me the importance of also looking at medicine label you pick up at pharmacies before you leave the store with them.

[applesxoranges, BSN, RN]

I have made med errors.

[Einna lvn]

I'm a new nurse working at a snf in ca with only 10 days of orientation and maybe less due to the place being understaffed. I dread going to work Almst every day. I had to learn lots of things on my own. I was a charge Lvn with 30-34 pts at that snf. It was almost my 3 months until I had a 1 big med error that led to the pt going to ER. To make the story short, this pt who is one of 34 pts I had was getting discharged to go home. I accidentally pulled the wrong med and gave it to her before discharge. Almost 2 hrs later I realized I gave the wrong med and told the Dr. He then called the pt at home and informed her to go straight to ER. Luckily the pt listened and went to ER. She ended of getting admitted and was doing fine. I did an incident report & reported the med error as soon as I caught it. 3 days later I get a call from my boss telling me I'm being suspended until theyre done investigating. I put in my immediate resignation the next day due to stress. I also found out that she wasn't going to fire me but corporate would have made her do it. They knew I wasn't orientated right since I started working. I'm just glad to be out of that place. That was the most stressful job I ever had and I invested in malpractice insurance soon after.