I just made a med error

barefootlady, ADN, RN · Oct 20, 2005

Nurcee,

You and the patient are in my prayers. I know you did all of the right things when you realized you made this error, so now just attempt to forgive yourself.

I am sorry for the loss of your family member.

K205 · Oct 21, 2005

Me too Nurcee-BIG one! I'm a new grad(LPN), and I had a crazy, hectic night on my unit(full moon) Well, I did a lot of things right, but I was so frazzled at the end of my shift that I took out the narc book, sat down, and looked it over to make sure I didn't miss signing for anybody. Well, one entry was for 10/17(this shift was the 18th), so I signed it with the coorect date(i thought I had forgotten to sign it originally)

Well, at narc count we were one over. It appeared that I had forgotten to give Oxycontin 40 mg(along with the 80 mg. ordered) I asked the oncoming nurse if I should just give it now (since I was embarassed and wanted a quick solution) He said "yes", so I trot down and give it to her. On the way back I'm thinking"Gee, I could've sworn I gave her both pills at the med pass" and voiced this to the other nurse. He shrugged, and starting preparing for his night. Well, He took one more look and realized I had written the wrong DATE! So, now this poor lady has 160 mgs. on board. She was monitored all noc, and is fine. Med errors are hair-raising, but boy do we learn. I'll stop and slow down, use my critical thinking,check,recheck to find a solution. If I had only stopped and said"No, that's not right" I would've saved this patient and myself from this situation. I cried all the way home, and until I went to sleep. I'm so sorry that this happened to you. It's a terrible lesson, but one you won't forget.:icon_hug:

http://www.smileycentral.com/sig.jsp?pc=ZSzeb066&pp=ZRXXXXXXXXUS

grammyr · Oct 21, 2005

Nurcee,

My thoughts and prayers are with you and the patient. You didn't say what the error was or if the patient was affected in any way. Hopefully the patient will be fine.

A few weeks after I started a new job I came in on a really busy afternoon. One of the nurses handed me a chart and asked me to give the meds ordered. Well, she handed me the wrong chart and I gave a woman Demerol 50mg and Phenergan 50mg shortly after someone else had already given it and had failed to chart it. Needless to say I nearly peed down both legs while I was trying to tell the doctor what had happened. This particular doctor apparently was known for throwing temper fits and I was trying to get prepared for the fallout. He was reallllly nice to me and said "It won't hurt her, she has 2nd and 3rd degree burns on both feet and will rest well." We monitored her for about 2 hours and let her go home. At least she was pain free when she left. To this date, I do not pick up not one medication until I get full report on all the patients that I will take care of and all my coworkers know better than to ask me to give a tylenol until all charting is caught up and meds are signed out.

mstigerlily · Oct 21, 2005

You were a very understanding patient. I have found that most patients are very understanding when things happen.

There is a plus side to making a mistake or having a patient go bad. You will NEVER EVER make that particular mistake again and you will be much more aware and knowledgeable about the signs/symptoms of whatever made the patient go bad. I have learned greatly from each and every error or poor patient outome I have experienced or seen.

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.

Nurcee · Oct 22, 2005

An update... patient appears to be fine. No nephro or vascular compromise. Thank you all for your warm wishes and prayers. Have a root analysis this coming week, but have an idea for my facility to enact so that there's less of a likelyhood of this happening to another pt. Again, thank you all for the prayers.

Tweety, BSN, RN · Oct 22, 2005

An update... patient appears to be fine. No nephro or vascular compromise. Thank you all for your warm wishes and prayers. Have a root analysis this coming week, but have an idea for my facility to enact so that there's less of a likelyhood of this happening to another pt. Again, thank you all for the prayers.

I'm glad to hear the patient is o.k. and that you are learning from this experience and trying to prevent a recurrence.

Editorial Team / Admin · Oct 22, 2005

An update... patient appears to be fine. No nephro or vascular compromise. Thank you all for your warm wishes and prayers. Have a root analysis this coming week, but have an idea for my facility to enact so that there's less of a likelyhood of this happening to another pt. Again, thank you all for the prayers.

Great, Nurcee. Who says prayer doesn't work??:)