I made my first med error, stupid me, why report it!??

[purse]

I was in the middle of my 8pm med pass and everything that is anything was going on, call bells ringing, people falling you name it. Just as I was about to go into a patients room to give him his pills, another resident rang their call bell, well I must have had the other resident on my mind and grabbed his pills by mistake! I ended up give patient 1 another patients pills. I immediately knew I did it and freaked out. The thought crossed my mind of just not saying anything...but I could never live with myself if something were to happen to the patient because of my error. I confessed what I did to the charge nurse (im a pca) and she freaked out on me, told me i was irresponsible and not paying attention. Well, she was even more mad because she had to call the doctor at 9pm, I told her I would call him if shed like, but apparently doctors, dont communicate with little pcas. All in all the doctor said it would be OK and the pills I gave the resident wouldnt harm him. i had to fill out an incident report and now EVERYONE knows Im the pca who is the idiot and gave the wrong pills...I know everyone knows because the charge nurse told 2 cnas and of course it will get around. Now, an inservice is ordered for "med errors and how to prevent them" on account of me. I am just very upset, because I know fellow PCAs who have done stuff like this and never reported it. It will probably go 'in my file' and now everyone will look at me like a dumb ass. Part of me wishes I just would have NOT reported it, but I think I am overall happy that I got the drs OK, because I would have been worried for days. I know a lot of my coworkers who miss doses, or have given night pills instead of day pills, etc! Nothing like this happens to them! UGHHHH. Thanks for listening to my vent hah.

[FutureNurse_8708]

I am so sorry that this happened to you! I feel that you did the right thing by reporting the incident...it shows that you care about the patient instead of putting yourself first.

Just give it some time, something will happen at the hospital...knowing how unpredictable it is, people will forget about what happened. It will all blow over before you know it!

[Forever Sunshine, ASN, RN]

You did do the right thing. Because for all you know the resident who received the other residents meds could have an allergy or adverse reaction to one of those meds.

[mad6w3]

I think its pretty cool that you are given the ability to pass medications. I'm not sure if thats the only thing you do at your job or if you also do CNA type of work. But you AND your employer should really consider revising this policy of people with your education to be giving out medication. I'm not trying to put you down or anything but we nurses have been given four years of education on medication administration and your also putting yourself at risk by giving wrong medications. You can be pulled into court for this type of situation. I'm just trying to say maybe you should step off of that responsibility and just do regular CNA work until you have more education. I do commend you for doing the right thing and reporting the med error. Seems like most people wont do that nowadays.

[Old.Timer]

Ummmm.....you report it because it's better for the patient if every med that goes into their body is known!!! Even a safe-sounding med can become deadly if it interacts badly with someone's system or other meds. Or if they get a "night pill" twice. But you know this already.

It's a shame your workplace doesn't support you.

There are workplaces which will welcome the humility and emphasis on patient safety you showed by reporting. All people who pass meds eventually make med errors. It's good to do your best to avoid them, and if you have too many of them, significantly MORE than your coworkers, I'd consider your facility's response justified. But you just had ONE error, recognized, reported. I think your workplace is out of touch if they're treating this like the end of the world, and I encourage you to move on to where your ethics will be better rewarded.

A summary of the OP's error, subsequent events, and the question, "why should I report it"? should be plastered on the wall of every nurse's station and nursing admin office in any facility where meds are administered. It should then be followed by Cinquefoil's beautifully stated response.

[LongislandRN23]

I do not mean any offense but I do NOT think that PCA's who are "med trained"- (what does that mean a 2 day course?) should be giving out medication. As nurses we are taught about medication and the five rights and safe administration ect from practically the first day of nursing school until the end and everyday in clinical. I think if you did NOT take a college level pharmacology course and did not take the NCLEX than you should not be handing out or dealing with medications nit because you are more likely to make mistakes because the proper way that meds work which is what we learn in pharmacology and the hard school nurses go through.

[Old.Timer]

i think its pretty cool that you are given the ability to pass medications. i'm not sure if thats the only thing you do at your job or if you also do cna type of work. but you and your employer should really consider revising this policy of people with your education to be giving out medication. i'm not trying to put you down or anything but we nurses have been given four years of education on medication administration and your also putting yourself at risk by giving wrong medications. you can be pulled into court for this type of situation. i'm just trying to say maybe you should step off of that responsibility and just do regular cna work until you have more education. i do commend you for doing the right thing and reporting the med error. seems like most people wont do that nowadays.

it's not cool to assume you know that op is practicing outside of her job responsibility. while i do not necessarily agree with the practice, it is my understanding that the rules and regs for med administration in non-acute care facilities are quite different. not sure of the specific requirements, but based on her description, my best guess is she is passing meds in a ltc facility and has completed specific certification to pass meds.

i commend op for her professionalism, accountability for her error and desire to learn from her mistake. sadly, in this instance, even with all her education, the rn's behavior was far from professional.

[Old.Timer]

this is my take on medication administration by non-licensed staff.

i do not believe for one second that it is wise to have non-licensed staff passing meds for 35-50 patients in ltc. h**l, i'd say it's not wise for licensed staff to do so.

i think if it is a true home environment, and staff has had "training" it may very well be appropriate. in fact, my best guess is, that that was likely the impetus for the development of the training classes. you know, an answer to the old, is a hha "monitoring" or "administering" meds ?

as far as i'm concerned, ltc facilities found an unintended "loophole" and play it to their advantage in their never-ending quest for enhanced profit margins.

[jollydogg_RN, ADN, BSN]

I do not mean any offense but I do NOT think that PCA's who are "med trained"- (what does that mean a 2 day course?) should be giving out medication. As nurses we are taught about medication and the five rights and safe administration ect from practically the first day of nursing school until the end and everyday in clinical. I think if you did NOT take a college level pharmacology course and did not take the NCLEX than you should not be handing out or dealing with medications nit because you are more likely to make mistakes because the proper way that meds work which is what we learn in pharmacology and the hard school nurses go through.

Wow dude, relax a little bit. You know most people on regular blood pressure medications at home don't even take their BP beforehand, right? I'm assuming the OP works at an assisted living facility (which is where most of the med passers work at), so half of those admitted probably take their own medications anyway. Most of these people here are on the same meds day in and day out, with very little medications changes. I'm on the fence about the issue myself, but what does a college course in pharmacology REALLY mean anyway? It means that I was able to memorize facts, common side effects, administration times and spit them back out for a test. Newer drugs come out everyday, and so do new guidelines, so relax. And discrediting how hard her training was? Not cool man. What if I compared LPN training to RN school in that manner?

The OP absolutely did the right thing, and it shows her integrity. People could use more of that trait. It's also unfortunate that your charge nurse reacted like that. It seems like she doesn't have your back. But just know that you did the right thing!

Once you lose your integrity, you don't have much else to stand on.

[purse]

Just so everyone knows,

I didnt know it was so uncommon for pcas to be giving medications...Anyways, I do pass meds, do cna type work, housekeeping, serve meals and help with all the other bs, in ltc assisted living...(which i can assure you not many of the residents are NOT "ASSISTED" living... )

anyways, I took one 8 hr course and now im allowed to pass medications. ive been doing it for quite a while, and I dont really disagree with it, it is not rocket science to be able to read a MAR and pour pills. and as far as knowing about the side effects, etc, there is a computer with GOOGLE.

Im not trying to step on anyones toes here, or offend nurses, Im just trying to justify what I do.

We are overseen by a LPN or Charge nurse... so its not like we have to know everything.

[Forever Sunshine, ASN, RN]

I do not mean any offense but I do NOT think that PCA's who are "med trained"- (what does that mean a 2 day course?) should be giving out medication. As nurses we are taught about medication and the five rights and safe administration ect from practically the first day of nursing school until the end and everyday in clinical. I think if you did NOT take a college level pharmacology course and did not take the NCLEX than you should not be handing out or dealing with medications nit because you are more likely to make mistakes because the proper way that meds work which is what we learn in pharmacology and the hard school nurses go through.

Most LPN programs are vocational schools. The pharmacology taught in LPN programs is not a college level.

And shes not more likely to make a mistake than you, me or the 30 year nurse is. LTC facilities are stressful and busy and noisy and full of interruptions. Its very easy to make a mistake doing a med-pass filled with distractions whether you have 2 hours of training or 30 years of experience.

Its very hard trying to focus when there's call lights, alarms, people walking past, residents wanting a pain pill, finger stick, a ride down to the dining room, getting up to go to the bathroom, to bed, trying to look for a way out, asking you all these questions, day nurses trying to finish their orders, administration walking around the floor, family members coming and going, the phone ringing, and an admission(or two) rolling through the door.

[JDZ344]

I'm a NA, and I made a horrible mistake once, not med-related though. I debated not reporting it, but then I thought: I will never be able to live with myself if I do not report this and the patient has an adverse effect because of that.

Always own up to any mistakes you have made. I do think it was unprofessional for your manager to tell all the CNAs though. Stuff like that should be on a "need to know" basis.

[bubblymom373]

You absolutely did the right thing by telling your CN. She absolutely did not act professional by her reaction. Keep your chin up and use this as a learning experience.