Have you ever made a med error?

kit3375 · Oct 23, 2006

Well today was it... I made my first TRUE medication error. Knew it would happen just didn't think so soon. I have only been out of school since May, and I've already made a mistake. Anyways... I gave Dilaudid 2mg instead of Morphine 2mg. I was trying to do everything the safe way by checking respirations, blood pressure, and giving the lowest ordered dose first. That didn't help. The Dilaudid is in the cabinet beside the Morphine, which I think is crazy. I guess I just focused on the Morphone in hydroMOROHONE instead of looking for Morphine. Don't really know what happened I was just devastated. I cried and felt like I couldn't breathe. No one acted like it was a big deal at all. The Dr. actually laughed at how upset I was. I already feel so insecure and I know that this is going to make it so much worse. Don't know if I'll ever be able to get this off of my mind!

i_am_evergreen · Oct 23, 2006

Well today was it... I made my first TRUE medication error. Knew it would happen just didn't think so soon. I have only been out of school since May, and I've already made a mistake. Anyways... I gave Dilaudid 2mg instead of Morphine 2mg. I was trying to do everything the safe way by checking respirations, blood pressure, and giving the lowest ordered dose first. That didn't help. The Dilaudid is in the cabinet beside the Morphine, which I think is crazy. I guess I just focused on the Morphone in hydroMOROHONE instead of looking for Morphine. Don't really know what happened I was just devastated. I cried and felt like I couldn't breathe. No one acted like it was a big deal at all. The Dr. actually laughed at how upset I was. I already feel so insecure and I know that this is going to make it so much worse. Don't know if I'll ever be able to get this off of my mind!

Hi Kit. Sorry about what happened, I know the feeling. Just try not to beat yourself up over this. Wish you the best.

askaham · Oct 24, 2006

Well today was it... I made my first TRUE medication error. Knew it would happen just didn't think so soon. I have only been out of school since May, and I've already made a mistake. Anyways... I gave Dilaudid 2mg instead of Morphine 2mg. I was trying to do everything the safe way by checking respirations, blood pressure, and giving the lowest ordered dose first. That didn't help. The Dilaudid is in the cabinet beside the Morphine, which I think is crazy. I guess I just focused on the Morphone in hydroMOROHONE instead of looking for Morphine. Don't really know what happened I was just devastated. I cried and felt like I couldn't breathe. No one acted like it was a big deal at all. The Dr. actually laughed at how upset I was. I already feel so insecure and I know that this is going to make it so much worse. Don't know if I'll ever be able to get this off of my mind!

Narcotics and other high-risk meds (ie. anticoagulants, electrolytes, etc) should always be double-checked independently by another licensed nurse.

manettohillnurse · Oct 24, 2006

to kit3375. you will get over this. don't let this spoil the rest of your career. this will make you all the more careful. it will always remain in the back of your mind, which is where it should rest. i'm sure that you'll go on to be a great nurse because you had the integrity to own up to your mistake !!!!!!!!!! i'm sure that the doctor who laughed at how upset you were didn't help too much. anyhow, good luck you'll be fine.

[color=#00bfff]sylvia

RN1263 · Oct 24, 2006

Well today was it... I made my first TRUE medication error. Knew it would happen just didn't think so soon. I have only been out of school since May, and I've already made a mistake. Anyways... I gave Dilaudid 2mg instead of Morphine 2mg. I was trying to do everything the safe way by checking respirations, blood pressure, and giving the lowest ordered dose first. That didn't help. The Dilaudid is in the cabinet beside the Morphine, which I think is crazy. I guess I just focused on the Morphone in hydroMOROHONE instead of looking for Morphine. Don't really know what happened I was just devastated. I cried and felt like I couldn't breathe. No one acted like it was a big deal at all. The Dr. actually laughed at how upset I was. I already feel so insecure and I know that this is going to make it so much worse. Don't know if I'll ever be able to get this off of my mind!

i'm the OP, and i can tell you that the devastation does wear off a bit....it's been about 2 weeks since my med error & although i'll be extra careful from now on, i'm not going to beat myself up about it anymore.

the first 2-3 days i was sooooo depressed literally i would just go back to bed every few hours during the day, but soon realized i had to get over it or i was going to make myself sick!

....so learn all you can from it (what you can change in the future), know that most nurses have made an error, & move on!....also, don't let any nurse w/ a "high and mighty" attitude about the subject get you down, they apparently don't understand you're already beating yourself up enough and don't need them getting their jabs in also!

...... this too shall pass!!!!:kiss

kukukajoo, LPN · Nov 4, 2006

Just wanted to say that this thread helped me pass my med admin lab with flying colors! Thanks to all who shared their stories and let me learn from you, it is greatly appreciated!

Teachingnurrse · Nov 5, 2006

Imagine this: You are working in long term care. Your patient load is 40 They all take from 5-15 meds apiece. You have one hour before and one hour after to pass from 200-600 pills before it officially becomes a med error. I personally can't imagine NOT making some sort of med error when your patient load is that heavy. 40 patients seems the norm here in the state of Colorado.

The first thing to do when you KNOW you've made a med error, be accountable. But what happens when you've passed meds to 40 or so people, done treatments, answered the phone, charted, supervised CNA's, among many many other things and you've made a med error and you don't even realize it.

Part of stopping med errors, especially in long term care is for nurses to refuse to accept assignments with such large patient loads. I've worked for a nusing agency for years.....large patient loads are the norm, not the exception. I don't accept more than 20 patients anymore.

I've made a few med errors myself during the years, but I've owned up to all of them. Then after all was said and done, I wanted to quit nursing.

Judy

pagandeva2000, LPN · Nov 5, 2006

Imagine this: You are working in long term care. Your patient load is 40 They all take from 5-15 meds apiece. You have one hour before and one hour after to pass from 200-600 pills before it officially becomes a med error. I personally can't imagine NOT making some sort of med error when your patient load is that heavy. 40 patients seems the norm here in the state of Colorado.
The first thing to do when you KNOW you've made a med error, be accountable. But what happens when you've passed meds to 40 or so people, done treatments, answered the phone, charted, supervised CNA's, among many many other things and you've made a med error and you don't even realize it.
Part of stopping med errors, especially in long term care is for nurses to refuse to accept assignments with such large patient loads. I've worked for a nusing agency for years.....large patient loads are the norm, not the exception. I don't accept more than 20 patients anymore.
I've made a few med errors myself during the years, but I've owned up to all of them. Then after all was said and done, I wanted to quit nursing.
Judy

The only thing I am wondering, is if the nurse really has a chance to challenge such an assignment with positive results. If, for example, you are an agency nurse walking into the facility and the agency does not tell you that this is the nurse:patient ratio, and you chose to leave, then, where does that leave your license? What if they report you to the state for job abandonment? Or, even if it is your normal job, and you refuse, it may be handled in the same way...or lead to suspension, insubordination and such. In the ideal world, we can refuse, but, I have seen disasterous results to those that actually did challenge this. Now, I would say that if we all decided to take that stand, the results may be better, but there are always the nurses that are afraid to for many reasons, and this would allow such things to continue.

pagandeva2000, LPN · Nov 5, 2006

Narcotics and other high-risk meds (ie. anticoagulants, electrolytes, etc) should always be double-checked independently by another licensed nurse.

Many nurses refuse to check with others at my hospital. Protocol states that insulin and narcartics should be double checked with another nurse, but there is no place on the MAR that provides a double signature, so, even if you did, the only signature they see is YOURS. I think that they should have a form filled out where it forces both nurses to actually have to double check and sign it, to be added to the chart for better accountability and compliance.

pagandeva2000, LPN · Nov 5, 2006

Just wanted to say that this thread helped me pass my med admin lab with flying colors! Thanks to all who shared their stories and let me learn from you, it is greatly appreciated!

Great to hear that. SOmetimes, sharing mistakes prevent other ones from happening.

potatomasher · Nov 5, 2006

i'm a senior rn student & i made my first med error last week. the nursing director said if i make another med error i'm out of the program. Has anyone done a med error as a student?
i know i'm going to be totally paranoid from now on giving meds, since i know if i mess up again i'm OUT!....ugh!

yikes...

medication error is the scary. i did not have a medication error during my student days...i was sort a paranoid. when i'm the medication nurse for the day, i'd arrive 30 minutes before duty starts to check all the orders in the patients' charts and kardex...kind of saves a lot of time and give you more time to recheck everything.

be careful, always observe the 5 R's in med administration.

jan

askaham · Nov 6, 2006

Many nurses refuse to check with others at my hospital. Protocol states that insulin and narcartics should be double checked with another nurse, but there is no place on the MAR that provides a double signature, so, even if you did, the only signature they see is YOURS. I think that they should have a form filled out where it forces both nurses to actually have to double check and sign it, to be added to the chart for better accountability and compliance.

As an instructor, I would see this refusal to double-check alot. Even if not overtly, it was obvious b/c they were not really carefully checking independently. I agree that the nurse cochecking should have the responsibility to chart. I always charted next to my students who administered meds so why can't a coworker chart next to you on the MAR? In this day and age when JCAHO is so hot on preventing med errors, I would think that nsg mgt at your hospital would want to have that kind of double-check system in place. The old saying of, "if it's not charted, it's not been done", is still true today.