How to Support a Coworker Who Has Made a Medication Error

[purplegal]

As nurses, we are supposed to do everything in our power to keep patients safe. As human beings, we are not perfect, so unfortunately, sometimes mistakes happen, including those that directly affect patients. As coworkers, we need to advocate for our patients, while maintaining good relationships with those we work with and providing support whenever needed.

Last night, a situation occurred in which I was unsure of how to respond. At our facility, narcotics are stored in a cabinet and counted before and after each shift, instead of being taken out by a Pyxis. At the end of our shift, during narcotic count, my coworker and I discovered a discrepancy between two medications.

One medication was listed as having two less than were actually in the medication card. We pulled that card aside to investigate, and not too much later, we found the opposite issue with another card, with two more being recorded than actually in the card. My coworker realized that while she had signed out on the right page, she had punched out from the wrong card.

This obviously meant that one of our patients had been given the wrong medication. Even worse, it involved a narcotic. As my coworker realized what she had done, I could see the panic in her face. She had already had a tough week, and it was obvious that this was adding to her stress.

Having never been in this situation myself, I wasn't sure what steps the coworker should take. So, I encouraged her to talk to one of our other coworkers, who had worked at our facility longer than any of us, who suggested that she contact the DON and on-call manager.

After discussing the situation with the DON, my coworker was informed that she would have to call on the on-call physician, write an incident report, discuss the situation with the patient and family, and continuously monitor and assess the patient for any adverse effects.

Although it was the end of my shift, and not my medication error, I did not feel comfortable leaving since narcotics were involved. So, I stayed around for awhile to see what needed to be done about the incorrect narcotic count, as well as to assist my coworker and the patient involved.

However, during this time, I was unsure of what to say to my coworker, so I just offered my assistance and to stay as long as she needed until she felt comfortable on her own. I wanted to say something encouraging or supportive to her, but was not sure what the right words would be. While it was important to not to dismiss the error as "unimportant" or "not something to worry about," this is a first time for someone who is otherwise an excellent nurse, well-liked by patients and staff, and a great resource.

[iluvivt, BSN, RN]

You can say something like this and then ask, " I am so sorry this has happened and is there anything I can help you with regarding this issue".Then keep it to yourself!

[aflahe00]

Just simply being there and letting her know that we are human and it's OK to make foolish mistakes. Yes that's right I said it. We all make mistakes especially as new nurses but we learn from them. I can guarantee that she will never let it happen again and be sure to pay extra attention to what she's doing from now on because now she knows how easily mistakes can happen. Bottom line- The patient was not harmed- end of story, move on. She will be a better nurse because of it.

[blondy2061h, MSN, RN]

Remind her that everyone makes mistakes and she handled it the correct way by putting the patient first, and reporting it appropriately.

[IHeartPeds87]

While it was important to not to dismiss the error as "unimportant" or "not something to worry about," this is a first time for someone who is otherwise an excellent nurse, well-liked by patients and staff, and a great resource.

Tell her that! Paraphrase that statement and it would be perfect!

Tell her that in your opinion, she is an excellent nurse, is well-liked by the patients and staff, and a great resource. Tell her that even this is a learning opportunity, and atleast the "first med error" transgression can be crossed off her 'hasn't happenned yet' list.

After stating that, I would then ask her why she thinks it happenned. Take her aside and be like, what was occurring at the time when she made the error. Brainstorm with her tactics that she can use to hep prevent this from occurring in the future.

I hung the wrong primary bag on one of my patients. Thankfully, no harm had come to the patient but I was rushing and had grabbed the wrong bag. One of the more experienced nurses who cought the error told me that I should try to scan the primary bags too- that would have prevented the error. She also told me that she understood that it wasn't always possible to scan the bags so what she started doing was she just slowed down and when she was labeling the bags with her name she also started putting a check in one of the corners of the sticker that meant, to her, that hse slowed down and checked the bag against the orders.

It was a great tip and is one that I have implemented.

So much about nursing boils down to HABIT and routine. Small alterations to a person's routine/habits can really have a large impact on patient safety.

My point is to focus on helping her alter her behavior to help prevent future mistakes. Also, brainstorm with her if she thinks any system errors also played a role in the error....could the two cards have been placed further apart so that they aren't so easily confused? If so, encourage her to discuss it with the DON.

My point is help her change her thought process from "oh no i'm an awful nurse and an awful person and I just suck" to "this is the problem, this is how I contributed to the problem, this is how the system contributed to the problem, and lets think about how we can fix the problem."