Have you ever made a med error?

KerenRN · Oct 19, 2006

I find it hard to believe that anyone could say that they have never had a med error. there are so many people playing a part in a hospital that it is more than likely to happen... Technically, if a doctor writes an order at 0810 and i'm giving my 0900 meds at 0840, i will try to look at the order before hand... but i can't always find the chart, so i go by what is on the MAR, which is incorrect by 0840... the pharmacy may fill a bin/drawer incorrectly, orders may not be signed of as they should. In the hospital I work we do not have computerized charting or anything, so we scan down our orders to pharmacy.... if the secretary forgets to scan or the scanner is working incorrectly.... all of these create an environment for potential med errors.

a person may not be at fault for a med error and the mistake(s) may not have been anything detrimental (G-d forbid) or you could simply not *know* it ever happened....but i don't think there are many people who can say they have never made a med error.

Basically, my point to the writer is to try not to be too hard on yourself. The number one reason for med errors: nurses are HUMAN! Just try to do better in the future.

pagandeva2000, LPN · Oct 19, 2006

Sometimes error can occur d/t inadequacies of the institution in which nurses are practicing, i.e. poor staffing with too many pts, etc.
The OP mentioned that the floor she was working was very chaotic. Also, I gathered she/he was performing these med passes w/o an instructor present and/or w/o much guidance from a preceptor.
She/he may want to explore any contributing factors, such as lack of guidance, being rushed, everybody trying to get into pexis @ once, how many pts. was the student responsible to giving out meds to, etc. and discuss these issues with the instructor.
Not saying the student should avoid personal accountability for the error but I do feel that all of the circumstances involved should be taken into consideration.

Absolutely!

pagandeva2000, LPN · Oct 19, 2006

I remember once, as a brand new nurse, I was giving insulin coverage, and the patient was to receive 3 units of insulin and I gave 2 units. I realized it as soon as I walked out of the patient's room, so, I got another syringe, added one more unit and went back to administer it. Things happen.

What has to be considered, may it be for a nurse or student, is that at times, administration comes down so hard on people, that when mistakes are made, not many people admit to them because of the punitive disciplinary actions. And, management does not admit that most times, it is because of shortened staff and too many distractions.

firstyearstudent · Oct 19, 2006

i am a first year nursing student with about 12 years experience in the animal field as a "nurse" doing anesthesia, intubations, iv's, med admin, cath insertion, radiography, you name it, it's been done...including med error, never administration, but caught myself with calculations (thankfully). i had my first med check off today, and through my own stupidity, made an error with my injection of reglan. talk about nerve racking....but rest assured i will, from this day forward, strive to remember this day! we are not perfect, mistakes will be made, and the ground has been broken for us previous to this. its about not being distracted and making sure you follow all the "rights". however, sometimes we see what we want to see also! dont beat yourself up, just use it as one of the best learning tools you can add to your "toolbox".

great attitude!!!! you are so right.

Klasseenurse · Oct 19, 2006

Oh God yes, but not as a student. I thought that I would drop dead from nerves. Thank heavens that no harm was done to the patient. There was an incident form to fill out, doctor had to be called, vital signs had to be taken, patient had to be watched for 24 hours, supervisors had to be alerted. I tossed and turned all night thinking about that medication error. I even got up in the middle of the night to call and check up on the patient. My supervisor told me that if I wasn't scared, I wouldn't be a good nurse. So yes, it has happened. Just remember, be extra careful next time and remember that we are human and do make mistakes. Good luck. :nurse:

BoonersmomRN · Oct 19, 2006

Not yet but I am only in semester 2/4. The most I have had is 3 clients and I have been able...so far....but it is ALWAYS on my mind...ALWAYS.....

i_am_evergreen · Oct 19, 2006

I was actually just kicked out of the nursing program (4th semester) for answering a question about a medication wrong and deciding not to dilute a dose of phenergan an anti-emetic (following the protocol in the drug book). I totally missed that on the sheet it said to dilute with 10 mls of normal saline. I caught it before giving it, but my teacher keeps arguing that i could have killed the patient if i were to administer it undiluted (NOT true). Looong story.

When she told me that i am being dropped, she went on and on about how unsafe that was, how incompetant i am, how i should never even consider getting back in the program, etc, etc, etc... you get the point. EXTREMELY unprofessional.

But anyhow, i plan on getting back in hopefully next semester.

~Talar~

AngelNurse25 · Oct 19, 2006

To all of the student nurses, I am a new grad working on a Renal/Diabetes floor with patiens who have multi-system issues. One of the RN's on the floor gave me some really great advise in relation to medication errors. She said "once you give it, you can't take it back"....some medications are exceptions to the rule, d/t antidotes, but you get the point. Just be sure to check, and double check, and triple check. I wish you the best and just take your time checking off meds. BE CAREFUL.... good luck!! :nurse:

AngelNurse25

i_am_evergreen · Oct 19, 2006

To all of the student nurses, I am a new grad working on a Renal/Diabetes floor with patiens who have multi-system issues. One of the RN's on the floor gave me some really great advise in relation to medication errors. She said "once you give it, you can't take it back"....some medications are exceptions to the rule, d/t antidotes, but you get the point. Just be sure to check, and double check, and triple check. I wish you the best and just take your time checking off meds. BE CAREFUL.... good luck!!
AngelNurse25

That is great advice. But the thing is that i checked that medication in three different books and 2 mentioned nothing at all about diluting, and 1 stated, "25 mg/ml or less may be given undiluted." The dose was 13.5 mg/ml so I still feel like was not that necessary.

AngelNurse25 · Oct 19, 2006

That is great advice. But the thing is that i checked that medication in three different books and 2 mentioned nothing at all about diluting, and 1 stated, "25 mg/ml or less may be given undiluted." The dose was 13.5 mg/ml so I still feel like was not that necessary.

I am not sure that kicking you out of the program for not diluting phenergan is really a fair punishment for the crime. You didn't technically make a medication error per the 5 rights, but I think your instructor should have been there with you teaching you that dilution is necessary. I was never taught that in school either, but once I got into the real world I learned to dilute due to the poor veins that our patients tend to have anyway. Sorry they did that to you :bluecry1: .

i_am_evergreen · Oct 19, 2006

I am not sure that kicking you out of the program for not diluting phenergan is really a fair punishment for the crime. You didn't technically make a medication error per the 5 rights, but I think your instructor should have been there with you teaching you that dilution is necessary. I was never taught that in school either, but once I got into the real world I learned to dilute due to the poor veins that our patients tend to have anyway. Sorry they did that to you .

I well it's a long story but you can see why else happened if you go to https://allnurses.com/forums/f17/venting-post-183301-4.html#post1886310

Still don't think it's fair. I mean what makes it all the worse is the way the talked to me.

manettohillnurse · Oct 19, 2006

yes i have. i gave digoxin to a patient who was to have an angioplasty and the dig. was on "hold". fortunately i reported this quickly and there was no harm done. i was in the hospital recently and was the recipient of three med errors one of which could have been fatal. thankfully i had the foresight to ask what the nurse was giving me for pain. i had a red wrist band on stating my allergies, there was a notice on my chart and a sign behind my bed yet i almost received the wrong medication. i think that once you've made one med error, you become especially careful after that. good luck to you in your future career.

manettohillnurse