I feel like the most incompetent nurse ever right now because of an incident that took place yesterday. I work on a Tele unit. I was on vacation for 12 days and yesterday was my first day back. I think that after being away for so long, everyone always takes a few hours to get back in the groove. Anyway, at the beginning of the shift I noticed that the section that I was assigned to had 2 empty beds and the other nurses had a full section, that means I was guaranteed at least 2 admissions. Now on a normal day I would have said something and asked for another patient so both me and the nurse beside me would have 4 patients each plus an admission. However because I was just coming back and I new the other nurses were tired, I said its no big deal, I'll do the 2 admissions.
Ok, so I got report, on one pt that we all knew because he was here for a week 2 wks ago, the night nurse told me that he was on a new "antibiotic" and it was running as we speak, I should take it down when it was finished so I agreed. After report and early morning assessment, I decided to go get all my patients' meds. I noticed the med in question (I forgot the name) and thought it did not look familiar. I made a mental note to look it up later before I administer it because it was due to be given at 2pm and it was only 8am. Also, there was none on the floor so I had to call the pharmacy to bring it up.
Anyway, the morning started to get busy, I had a transfer from the CCU, then I had another admission from the Cath Lab and to top it off they decided to discharge one of my other patients. I still had to do the other nursing duties such as administering meds, patient care, going to rounds and of course the regular dcumentations. In the midst of this, one of the pharmacists was making her rounds and I remembered the med so I went over to her and asked her if she could bring it up for me, she asked me what it was and I read it off the comp to her and she said sure, she would verify it and get it to me as soon as possibe and she did.
So now the empty bed where the discharged patient was had another patient coming up. This makes my 3rd admission! So now I'm getting overwhemed and the nurse beside me sees this and offered to do the admission paperwork for this new patient. I then went and administered the 2pm meds. I remember while administering the med, which I did not get to look up because now I'm overwhelmed, tired and hungry. I said him, "they're giving you a new antibiotic now?" and he said yes. I didn't think much of it also because this was the third dose he was receiving without any adverse reactions and he did not seem like anything was wrong with him. He was ambulating in the hallways and to the family room most of the day like he normally does. He also complained about the food and I ordered him something else. No reason for me to think something was wrong with him. No muscle pains, weakness,rashes, respiratory or cardiac distress at all.
Anyway, this morning, I'm off today, my nurse mgr calls and said the "antibiotic" was actually a paralytic used in the OR and the doctor who prescribed it prescribed it for the wrong patient. This med apparently should have never even been brought to my unit. Now this is going to be a peer reviewed case and she doesn't know what is going to happen with me and the other nurses who were involved in his care, the prescribing doctor and the pharmacists. I agree, I was wrong and I'm not making any excuses, I should have looked it up. I shouldn't have trusted what the night nurse said, not that she's a bad nurse, just that you never know. Thank God, the patient did not show any adverse reaction but I still feel lower than dirt right now.
There is a whole chain responsible for this error starting with the doc who prescribed it, the night nurse who noted it, the pharmacist who brought it, whoever made your assignment, and you who gave it. We are all human and we all make mistakes. Do not beat yourself up and do not let them signal you out for this error.
This is a SYSTEMS error. Thank god no harm came to the patient! Why would a med not commonly given outside of the OR not be flagged in some way? Especially a paralytic?!?!
Your assignment was too heavy with too much going on. You did the best you could period. The fact that you caught the metformin error shows you are a conscientious nurse.
The peer review process should be utilized to find a way to prevent an error like this from happening again. It should not be a punitive thing and it should include EVERYONE involved, not just you. Do not let them make you feel like an incompetent when you meet with them. Acknowledge your part in the error by not looking up the medication but also acknowledge the system errors that contributed.
Specializes in Pain Management, FNP, Med/Surg, Tele.
It is what it is. Thankfully you got a union behind you. Have you talked with your union rep? You do realize that in the end it doesn't matter how many times it was a mistake before it got to you, that in the end you should have caught the mistake. I don't say this to be mean; I say this to prepare you for what's coming. Own up to it and don't make excuses is my advise. Of course follow what the union's lawyers will advise.
My thoughts are with you.
Hi tyvin,
I haven't spoken to the union rep as yet. This just happened this am and I do not go back to work until Friday. I will call the Rep if the Nurse Mgr wants to discipline me. I don't think you're being mean. It happened and I can't take it back. It would have been awesome if I caught the mistake but I didn't. I'll deal with the consequences. I have to.
Specializes in Pain Management, FNP, Med/Surg, Tele.
I'd like to suggest that you get an electronic drug guide which you carry with you always (it's ever a good excuse to get a smart phone). I still carry my Palm PDA with me every shift and I still look up every drug with which I'm not completely familiar.
Sometimes when we're busy - as you well know - there just isn't a free moment to "look it up later."
Hello :)
I have MPR on my blackberry. It is what it is, I messed up
This is definitely a huge systems error. And from these mistakes, everything is reevaluated and precautions are taken to prevent it from happening again. EVERYONE learns something and that's why there is Quality Improvement.
One thing that gets me. This patient did not get any effect from the paralytic?? He was ambulating with it and showed no actual effects of the medication? Very strange....
Specializes in Pain Management, FNP, Med/Surg, Tele.
This is definitely a huge systems error. And from these mistakes, everything is reevaluated and precautions are taken to prevent it from happening again. EVERYONE learns something and that's why there is Quality Improvement.
One thing that gets me. This patient did not get any effect from the paralytic?? He was ambulating with it and showed no actual effects of the medication? Very strange....
Absolutely no effects. He is a 31 yr old Sickle Cell Anemia and CRF on HD patient who came in with C/P and dyspnea and later diiagnosed with RLL PNA and being treated with Zosyn and Vanco IV.
i just remembered something my dad used to say from time to time.
"you're a human being and mere mortals make mistakes sometimes. since your error didn't result in someone's death, and you didn't do it with malice aforethought, it's correctable, in all likelihood. you learned from it and that will make you more cautious and careful in the future and that's a good thing."
that quotation fits your situation. my dad was an attorney/physician.
Specializes in Pain Management, FNP, Med/Surg, Tele.
I also wanted to point out just how smart you are to have your own malpractice insurance and that this is precisely the kind of case where you don't want to rely on the hospital to cover you.
Best of luck to you.
(And you're not incompetent - you made a mistake - two very different things.)
Thank you so much. You guys are really helping me to feel better. :redbeathe
Specializes in Pain Management, FNP, Med/Surg, Tele.
most important the guys all right. they can't come down too hard on you because a doctor started the chain of mistakes. They can't kill you, they can't throw you in jail, they can't make you ware clown shoes. all that will happen is they yell and scream a lot about Nursing Protocall, and the Five Rights and other stuff. Big deal. Next time, and there will be a next time if some one is getting a drug that you don't know about, look it up...the very moment after report. Nothing is more important then for you to know the IV drugs that are running into your patient. If and I say if they get dirty mention the magic word "Lawyer". That magic word can make anything all better.
Hahahaha "lawyer'.
Yes, this is definitey a really big lesson that I'm learning and I'm heeding to it and will never ever administer any drug that I am not familiar with no matter how busy I am. I don't want to hurt any patient, I know better than that.
Specializes in Pain Management, FNP, Med/Surg, Tele.
Tone,
There is a whole chain responsible for this error starting with the doc who prescribed it, the night nurse who noted it, the pharmacist who brought it, whoever made your assignment, and you who gave it. We are all human and we all make mistakes. Do not beat yourself up and do not let them signal you out for this error.
This is a SYSTEMS error. Thank god no harm came to the patient! Why would a med not commonly given outside of the OR not be flagged in some way? Especially a paralytic?!?!
Your assignment was too heavy with too much going on. You did the best you could period. The fact that you caught the metformin error shows you are a conscientious nurse.
The peer review process should be utilized to find a way to prevent an error like this from happening again. It should not be a punitive thing and it should include EVERYONE involved, not just you. Do not let them make you feel like an incompetent when you meet with them. Acknowledge your part in the error by not looking up the medication but also acknowledge the system errors that contributed.
Thank you very much for your reply. I don't know why I was blaming myself so much, I didn't even want to think about the other people, I was just thinking about myself. I am too hard on myself sometimes.
Specializes in Pain Management, FNP, Med/Surg, Tele.
i just remembered something my dad used to say from time to time.
"you're a human being and mere mortals make mistakes sometimes. since your error didn't result in someone's death, and you didn't do it with malice aforethought, it's correctable, in all likelihood. you learned from it and that will make you more cautious and careful in the future and that's a good thing."
that quotation fits your situation. my dad was an attorney/physician.
thank you very much, esp for the quote. i'll remember to tell them that at the review if i'm invited.
Specializes in Neurovascular, Ortho, Community Health.
You were not the only person who messed up. The doctor wrote the order. The pharmacist filled the order. You then came and gave it. In this instance, all checks & balances failed. A good hospital is of the mindset that the key to performance improvement is studying WHY something happened, WHY the process failed, NOT to point fingers/place blame. So, I think everyone involved and even your floor and hospital may look at the process and see how it can be improved to prevent further repeats. Med errors should not be a blame game!
That being said...I know you know this now but I must say...
Take home message: Never give a drug if you don't know what it is! I know I sound like your nursing school instructor, but what if it was something that needed vitals checked for parameters or something. I have epocrates on my phone, and I whip it out all the time to look stuff up. It's better to give the med late to look it up (or you could've asked the pharmacist or even called them back to ask).
Specializes in Pain Management, FNP, Med/Surg, Tele.
You were not the only person who messed up. The doctor wrote the order. The pharmacist filled the order. You then came and gave it. In this instance, all checks & balances failed. A good hospital is of the mindset that the key to performance improvement is studying WHY something happened, WHY the process failed, NOT to point fingers/place blame. So, I think everyone involved and even your floor and hospital may look at the process and see how it can be improved to prevent further repeats. Med errors should not be a blame game!
That being said...I know you know this now but I must say...
Take home message: Never give a drug if you don't know what it is! I know I sound like your nursing school instructor, but what if it was something that needed vitals checked for parameters or something. I have epocrates on my phone, and I whip it out all the time to look stuff up. It's better to give the med late to look it up (or you could've asked the pharmacist or even called them back to ask).
Thanks for your reply,
I always check vitals before giving meds that can lower B/P and P, that is not even a second thought. As a matter of fact, 2 of my patients yesterday were running low B/Ps and I had to recheck their B/Ps a few times before making the decision of giving the meds or not. Also, one started getting delirious, sweaty and nauseous. I checked his B/P, P, T, O2 Sat & BG and straight cathed him to get urine for UA & C. I pushed Reglan 10 mg IV, gave Tylenol 1GM and then called the MD to get the orders. Turns out, his sugar was 112, T=102.6, B/P & O2 Sat= WNL and HR was in 130's. UA came back positive for Leuks, Nitrites, Many bacteria and RBcs. But I know what you're saying though, check all meds. I "normally" do.
thank you very much, esp for the quote. i'll remember to tell them that at the review if i'm invited.
Sugarcoma, RN
410 Posts
Tone,
There is a whole chain responsible for this error starting with the doc who prescribed it, the night nurse who noted it, the pharmacist who brought it, whoever made your assignment, and you who gave it. We are all human and we all make mistakes. Do not beat yourself up and do not let them signal you out for this error.
This is a SYSTEMS error. Thank god no harm came to the patient! Why would a med not commonly given outside of the OR not be flagged in some way? Especially a paralytic?!?!
Your assignment was too heavy with too much going on. You did the best you could period. The fact that you caught the metformin error shows you are a conscientious nurse.
The peer review process should be utilized to find a way to prevent an error like this from happening again. It should not be a punitive thing and it should include EVERYONE involved, not just you. Do not let them make you feel like an incompetent when you meet with them. Acknowledge your part in the error by not looking up the medication but also acknowledge the system errors that contributed.