I Made an Absolute 'No-No" Mistake :(

[frustratedRN16]

Hi Everyone... I have been a nurse with an exceptional record for three years. I was in the process of being hired on as a unit manager in the next few days......and then....I lost my brain in the middle of an absolute hellish shift. One of my patients exhausted all of her available meds that I could give her and I listened to her beg for hours after all trying all available nursing interventions. I had the brilliant idea to give her Benadryl without calling the doctor. I know better than this. I don't even know how to explain or even justify what I could possibly have been thinking. I have never been afraid to fight for orders before. I have no one to blame but myself. I have been surfing the web all day trying to see if there was hope at the end of this tunnel......I lost my job today and I waiting to hear from the board in a month or so. My DON says that I wont lose my license but will have a letter of admonition on my record forever for this mistake. They say that life is all about learning lessons but...... I don't want to do LTC nursing ever again. It is horribly stressful. Im going to pick myself and be dang sure I NEVER make this mistake again. any ideas???

[Here.I.Stand, BSN, RN]

I did have to sit with a nurse once during state survey because she had started oxygen on a resident without an order. The surveyor was really trying to make an issue of this. Of course we started oxygen. The resident was having chest pain, shortness of breath, and sats in the low 80s.

That surveyor is clearly too ignorant for that job. Oh my freaking goodness... do we need orders to start chest compressions too? Supplemental O2 for sats in the low 80s is clearly indicated per BLS protocols.

[RescueNinjaKy]

Just to clarify, why did you give the Benadryl? Was the patient asking for it? Or did you give it to snowball the patient?

[CapeCodMermaid, RN]

That surveyor is clearly too ignorant for that job. Oh my freaking goodness... do we need orders to start chest compressions too? Supplemental O2 for sats in the low 80s is clearly indicated per BLS protocols.

I don't think it was the same surveyor but one walked in to a place where my friend was the DON because the family called and said their grandma wasn't getting the correct IV fluid (by the way, they never mentioned this to the nurses). So in walks the surveyor and after doing all the preliminary stuff they do (so they can get their 8 hours in at one facility) goes to look at the MD orders which read: Half normal saline IV at 50 ml per hour for 72 hours. Surveyor looks at what was hanging and said: "Oh, this is incorrect. The order was for half normal saline. This bag says 0.45% NS and and everyone knows that half is 50%.

Um, hmmmm, not when NORMAL SALINE is 0.9%!!! People don't become surveyors because they are the best and brightest-although I do know some surveyors who are quite bright and very fair when they come into the building.

[SmilingBluEyes]

No one is beating you up. You deserve NO ridicule. Sounds as if you more than learned your lesson.

I wish all the best, truly. I am not judging you. I hope all good things for you.

[gigi_rn]

If pt wasn't in pain, what was she wanting exactly?

[gigi_rn]

If they are treating you like this, probably just as well not to take a management position with them. Best wishes!

[gigi_rn]

Also, your DON has no business saying what the Board will do.

[Been there,done that, ASN, RN]

I have a few questions:

What was the Benadryl given for?

Did the pt experience an adverse/allergic response from the medication?

Did you override the medication or had "leftover" in a vial from another pt?

Don't get me wrong, you definitely were beyond our scope of practice but I am curious as to why you did what you did? (Sorry if that sounds abrupt, I'm a male nurse, its what we do lol.)

In relation to the seriousness of this post, any lol is not appropriate.

Benadryl potentiates opiates. I'm a female nurse.. knowing this is what we do.

[bgxyrnf, MSN, RN]

I NEVER make this mistake again. any ideas???

Perhaps the most effective way to ensure you never do this again is work in a facility where all meds come out of a dispensing machine and must be charted in an EMR utilizing a verification scanner or portable rover.

Honestly, though, I would be stunned if you ever did anything like this again. This sounds like a sufficiently stressful and memorable event that will be permanently imprinted in your long-term memory.

Giving 25mg of PO Benedryl really isn't any big deal but the system just doesn't work that way (as we all know) so we just don't go there. I have given family members some ibuprofen or APAP out of my personal bag but for a patient? Nope, never ever... only meds ordered by the doc, verified by the pharamacist, and dispensed through the appropriate means.

I imagine that things will all work out in the long run and there's no need to continue to beat yourself up over it. You cannot change anything that happened but you certainly have control over the future.

Keep your chin up and look yourself - and everyone else - straight in the eye. I once made a serious med error and, hard as it was, that was the approach that I took. Over time, the sting faded and I got some positive comments from colleagues about the dignified manner in which I conducted myself and owned up to it, even sitting in room full of people including the manager of risk management, hospital counsel, the nursing director, two pharmacists, a couple of fellow nurses, and a physician.

This, too, shall pass.

[bgxyrnf, MSN, RN]

I deserve the ridicule.

No you don't.

Nobody deserves ridicule for a lapse in judgment.

Correction is warranted. Education is logical. Admonition and even probation are perhaps appropriate.

Ridicule, though?

Nope, that's just mean-spirited...

[iluvivt, BSN, RN]

You may only be mandated by the BRN to take a course on scope of practice or other similar admonishment