I just made a med error

Celia M, ASN, RN · Oct 20, 2005

We have all made mistakes and med errors, it is an awful feeling. Make sure that you fill out an incident report and document there who you notified and when. Also document on it what else was going on. You may also want to chat with your manager or if you have someone who is a mentor for you. I'm thinking of and prayong for you and your patient.

rn in 3 years · Oct 20, 2005

I am so sorry you are going thru this (the med error and the death) :icon_hug: I hope everything will turn out ok for you.

Editorial Team / Admin · Oct 20, 2005

I am just sick to my stomach. I just made a horrific med error last night (12 hour night shift). Wrong med and wrong route on the wrong patient. I was distracted (impending death in the family-now planning funeral this morning) and extrememly physically and emotionally exhausted. This is my 1st error (that I know about) since I got my RN. To make matters even worse, this was my least metabolicaly stable of all my patients too and it wasn't a 'simple' mistake. I really screwed this up. I am just sick to my stomach with worry about her and don't know what to do.
I just am so horrified. Please, for any who read this, please, please send a prayer for her. I am just so sorry.

Hi, Nurcee. I am so sorry about the error. Please know this happens to all of us, at some point in our careers. Small error and large ones, too. Just one thing, and, I am sure you did this, you reported thru the proper channels, yes?

Now, just try to fall back and regroup. Don't beat yourself up over this. I wish you well. I am so very sorry for the loss in your family.

I will keep the patient and you in my prayers.

Nurcee · Oct 20, 2005

Don't beat yourself up over this.

I think I need a beating over this. I just hope she's going to be ok.

Celia M, ASN, RN · Oct 20, 2005

Nurcee, You don't need a beating over this, please just learn from the mistake. With the death in your family it is understandable that you were not in top form. If you keep beating yourself up about this, you will not move and learn. Please take time for yourself, grieve for your family member, look after yourself and your loved ones. We all make mistakes, the tough part is to accept that it has happened, learn from it and move on.16 years ago I gave double the dose of atropine for a preop to a peds patient who happened to be the son of an internist who was at the bedside when I did it!!!. No ill effects apart from non symptomatic tachy but I beat myself about it for ever. The doc was great and he moved on but I couldn't look him in the eye until I stopped worrying about and started double checking my orders and not rushing. Know that you are in my thoughts nd prayers and this difficult time, can you take some time off work, are you eligible for Bereavement leave. Hang in there. Celia

pricklypear · Oct 20, 2005

((((((Nurcee)))))) Hugs, not beatings, here!! We've all made errors, like Siri said, big and small. You have taken responsibility. If you feel comfortable with your manager, talk to her/him. They've been there, too. You won't accomplish anything by worrying and beating yourself up. Making errors helps us all to become more vigilant and careful. They also help us to be aware of the potential for other things to intrude into our work, and learn ways to deal with it - so we can practice safely. It's impossible to drop life at the door when we go to work, but we can learn to shift our focus for the periods of time that we need to. We just need to recognize these times and take extra steps. :icon_hug:

Nicky032605 · Oct 20, 2005

I am just sick to my stomach. I just made a horrific med error last night (12 hour night shift). Wrong med and wrong route on the wrong patient. I was distracted (impending death in the family-now planning funeral this morning) and extrememly physically and emotionally exhausted. This is my 1st error (that I know about) since I got my RN. To make matters even worse, this was my least metabolicaly stable of all my patients too and it wasn't a 'simple' mistake. I really screwed this up. I am just sick to my stomach with worry about her and don't know what to do.
I just am so horrified. Please, for any who read this, please, please send a prayer for her. I am just so sorry.

I just wanted to tell you about my experience as the patient when this happened. I was getting my hickman catheter flushed one morning in the hospital and instead of flushing it with Heprin, she must have grabbed something else (I think I heard someone say a steroid). No one knew about it til a couple minutes after she left I had trouble breathing. All of a sudden there were a bunch of people in my room and I wasn't able to breath. Some how I was able to breath agian and all was fine. It was so early in the morning that the nurse probably didn't realize what she had grabbed. I remember the look on her face and I felt so bad for her. I can't imagine the guilt that she must have felt.. and I am sure she always looks to see what she is grabbing now. My case must have been given to someone else because of it, and I don't know what her punishment was for it, but I never held it agianst her. Anything can happen when your in the hospital as far as I am concerned. We learn from our mistakes. To err is human.

Tweety, BSN, RN · Oct 20, 2005

I'm sorry this happened to you. Best wishes for the patient and you.

jnette, ASN, EMT-I · Oct 20, 2005

Hi, Nurcee. I am so sorry about the error. Please know this happens to all of us, at some point in our careers. Small error and large ones, too. Just one thing, and, I am sure you did this, you reported thru the proper channels, yes?
Now, just try to fall back and regroup. Don't beat yourself up over this. I wish you well. I am so very sorry for the loss in your family.
I will keep the patient and you in my prayers.

Ditto the above.

It is a horrifying experience.. one which I have been spared SO FAR... but I'm sure my day, too, will come. I dread reading about these, as I can feel the horror, fear, shame, and worry described by all who have had this occur.

All I can offer is (((HUGS))), and prayers that your patient will be ok, and that you will be able to forgive yourself and move on.

dekatn · Oct 20, 2005

Nursee, please forgive yourself, we all make mistakes, we don't make them on purpose, hence, mistakes. I never will forget when I was a new nurse, I was working with an orientee, we decided I would give meds down one side of the hall and she would give them down the other side. Back in those days we weren't as hip on locking the med cart as we are now. Anyway, when I got to the end of my hall the other nurse was still a good ways down hers so I thought I would help out and start from the last room on her side. Well, needless to say, major mistake. I pulled up the meds, they hadn't been signed off on the MAR, took them in to the pt. she took them with no c/o. About the time I was coming out of the room, the orientee walks up and says,"Oh I have already given Mrs. So and So her meds, I just haven't signed off for them". My heart just stopped I thought I would throw up!! That was the worst feeling in the world. I really didn't want to call the doc, he had a reputation for chewing nurses up and spitting them out, but he was really understanding about it, as was the pt. She (the pt.) told me later, I thought I had already taken those pills. The pt. was fine, no problems other than a lower BP than normal. I haven't thought about this in quite some time, but, just remember we are only human and humans make mistakes. My thoughts and prayers will be with you during this trying time in your life. Please take care and don't be too hard on yourself. You aren't alone.

Stitchie · Oct 20, 2005

Nurcee: I too have made med errors and felt like throwing up endlessly afterwards. I misread a label of Decadron; it came in 10cc multi-use vials, 10mg per cc. (100 mg Decadron total) We had a patient who was having a bad, bad stroke, herniating his brain stem. With the charge nurse in the room, looking over the meds I was dishing out, neither one of us saw that I had given the entire 100mg to this patient. The charge nurse was upset but more so because we had to rush this patient through for CT and the neurosurgeon (not that it would have helped in the long run). The most difficult part is facing the doc who wrote the order. He could have ripped my head off; I've never been so frightened in all my days (and I've had some pretty bad days, especially of late). Anyway, Dr. Wonderful said don't worry, it won't hurt him ( I was watching his blood pressure spike up, a side effect of the Decadron). Lord I was so humiliated and I too, felt that I deserved a horse whipping. The doc, bless his heart, was so very, very understanding about this, and for that reason alone I stayed in ER nursing.

It's easy to make that error when you are running short on time and you want to do some good for your patient. To have the charge nurse in the room as a 'back up' (I was just a month or so off orientation, so I asked for her help, and she was good about it) and not catch this means we failed on two fronts -- hers and mine.

Nothing happened, but I am much more careful now. This actually became a sentinal event in our hospital for pharmacy to change the packaging, because it had happened so many times before. An overdose of Decadron won't really kill you but a patient as unstable as a herniated brianstem , well, that could spell trouble for the patient. Even though his prognosis was not good, my own feelings of professional responsibility got me loud and clear. This was a big mistake, a horrible mistake, and the doc saw that I was in tears after the patient went to SICU. He gave me some of the kindest words imaginable: we are human, first and foremost. Good nurses make mistake. Good doctors make mistakes. Great professionals learn from them and move forward, knowing that they have accumulated an "It's my turn" sort of feeling when the error happens.

There may be those who haven't made errors, some who by nature more slowly and methodically throughout the process, and there is something to learn there.

Try to maintain a sense of perspective. We've all wanted (and needed) to just break down and howl after an event like this. I did, and it helped. Falling apart after nearly killing (or so I thought) a fragile patient was cathartic for me, and in the end, a great learning experience.

Try to put it behind you. You have too much to offer nursing and we need bright, capable, ethical professionals on our team.

Good luck to you.