I made my first medication error :(

Trauma Columnist · Feb 10, 2008

Go back to bed. Lantus last 24 hours and sometimes is given in the morning...though usually at night. They will monitor the pts blood glucose and give sliding scale today as needed. Fill out the incident report, learn from you mistake and go on. No harm done.

Go to sleep!

rkrs6673 · Feb 10, 2008

Thanks for your reply. I guess I am so concerned because this patient has a new onset of DM and came in with a blood sugar of 600. He was on Q2h finger sticks when I left. Also, when I left left his blood sugar was 129 and he also go 2 units of Novolog. I will find out how to fill out the incident report when I go in tommorow.

snortzmom · Feb 11, 2008

I made my first med error yesterday too. It is the worst feeling ever. The doc gave me a verbal order (I should have known better) for 2grams Claforan IV. I gave it, and then a random doc came in to see the patient and took the chart. No where to be found. I kept looking for it to chart my med, and about 20 minutes later, I saw it in the hands of a float nurse who saw the written order and gave the med also. Stupid, stupid me. Well, I learned from this experience that unless someone is dying, never give a med based on a verbal order. I hope you feel better. You aren't alone. I couldn't sleep last night either due to my mistake. We WILL make it through our first year! Chin up.

nursemike, ASN, RN · Feb 11, 2008

I made my first med error yesterday too. It is the worst feeling ever. The doc gave me a verbal order (I should have known better) for 2grams Claforan IV. I gave it, and then a random doc came in to see the patient and took the chart. No where to be found. I kept looking for it to chart my med, and about 20 minutes later, I saw it in the hands of a float nurse who saw the written order and gave the med also. Stupid, stupid me. Well, I learned from this experience that unless someone is dying, never give a med based on a verbal order. I hope you feel better. You aren't alone. I couldn't sleep last night either due to my mistake. We WILL make it through our first year! Chin up.

Was this your assigned patient? If so, the float nurse made the error. You never medicate someone else's patient without consulting them--NEVER! I give meds on verbal orders every day--pt in 10/10 pain, get an order for a pain med, give it now and write it after. In extreme cases, it isn't unheard of for an experienced nurse to give the med, then get the order (not legal, but it does happen). You never medicate someone else's patient without consulting them. Would you wait for a written order to push Narcan?

Nurses are sometimes overly territorial. It can lead to conflicts when someone is just trying to help out. But this example is why we're territorial, and why we don't "help out" by stepping on other nurses' toes.

If you were the nurse of record for this patient, the float nurse was only authorized to act under your delegation, and since you obviously did not delegate the task, she had no business treating him, because you never medicate someone else's patient without consulting them. Heck, I'd probably check with you before I got him an extra pillow.

nursemike, ASN, RN · Feb 11, 2008

At my facility, we don't give insulin until it's verified by a second licensed nurse. It's a pain in the behind, but does help avoid errors such as the OP's. But, as previously noted, at least this one is a fairly easy fix.

Even if it isn't required, having a peer take a look at a high alert med is probably a good idea, and more and more places are requiring it.

snortzmom · Feb 12, 2008

I know, which is why I am so confused. When I asked her why she gave the meds in my room without consulting me (in a nice way) she said that she was trying to keep the flow of the department going. Anyway, I am the new nurse and basically everyone's target so I basically need to cover my rear and never give a med based on a verbal order, unless of course it puts the safety of the patient at risk (like the Narcan example).

TraumaGirl1018 · Feb 12, 2008

I made my first med error yesterday too. It is the worst feeling ever. The doc gave me a verbal order (I should have known better) for 2grams Claforan IV. I gave it, and then a random doc came in to see the patient and took the chart. No where to be found. I kept looking for it to chart my med, and about 20 minutes later, I saw it in the hands of a float nurse who saw the written order and gave the med also. Stupid, stupid me. Well, I learned from this experience that unless someone is dying, never give a med based on a verbal order. I hope you feel better. You aren't alone. I couldn't sleep last night either due to my mistake. We WILL make it through our first year! Chin up.

i REALLY dont see how this med error is your fault...as someone stated, that float nurse should not have just administered a drug to your pt without first mentioning it to you!

nursemike, ASN, RN · Feb 12, 2008

I know, which is why I am so confused. When I asked her why she gave the meds in my room without consulting me (in a nice way) she said that she was trying to keep the flow of the department going. Anyway, I am the new nurse and basically everyone's target so I basically need to cover my rear and never give a med based on a verbal order, unless of course it puts the safety of the patient at risk (like the Narcan example).

CYA is hardly ever a bad idea, and it's fairly normal to be a bit diffident when you are the newbie. Off-hand, I can't think of any likely scenario where waiting a few minutes for a written order for an antibiotic would have been wrong. Just be clear in your own mind that nothing you did was "stupid." The float made the med error, and was actually acting without an order. The day will come when you are more confident and assertive, and you'll hand someone their head if they pull a stunt like that--in a calm, professional manner, of course. (It's important to be civil, but it isn't always necessary to be nice.)

Virgo_RN, BSN, RN · Feb 13, 2008

I feel so bad.. I have made my first medication error today. I was to give my patient 20 units of NPH. Instead I gave 20 units of Lantus. The thing is I even double checked the order because I recall telling the oncoming nurse that I was going to give the scheduled 7 am Lantus and then I went to go and double check the amount. Anyway the nurse who took place (wonderful nurse - My preceptor) called my house at nine am to see if I gave the patient NPH of lantus. She told me the order was for NPH and I told her I was 100% sure I gave Lantus and I also charted that I gave lantus . I asked her did I need to come back in and file a incident report and if the patient was ok. She said no everything will be fine but I am so scared and am unsure as to what I am going to do. I haven't been able to sleep all day long.... I am so worried about the patient. I just called up to the hospital and the nurse is busy with the other patients..... I am just so sad and nervous as to what will happen to my patient.

Lantus does not rise to a peak like other insulins, but remains at a steady bloof level over a twenty four hour period, so the risk of hypoglycemia is lower with Lantus than with other insulins.

At my facility, insulin dosages are checked by two licensed persons.

Virgo_RN, BSN, RN · Feb 13, 2008

I made my first med error yesterday too. It is the worst feeling ever. The doc gave me a verbal order (I should have known better) for 2grams Claforan IV. I gave it, and then a random doc came in to see the patient and took the chart. No where to be found. I kept looking for it to chart my med, and about 20 minutes later, I saw it in the hands of a float nurse who saw the written order and gave the med also. Stupid, stupid me. Well, I learned from this experience that unless someone is dying, never give a med based on a verbal order. I hope you feel better. You aren't alone. I couldn't sleep last night either due to my mistake. We WILL make it through our first year! Chin up.

No, it was not your mistake. It was the float nurse's mistake for giving a medication without checking with you first.

Jovichick · Feb 16, 2008

Here's my first med error.

I do suffer from anxiety issues. Nothing would make my mind draw a blank more than when my preceptor would stand right next to me and stare at my face as I was trying to think. 2 of my patients were to receive IV Mg. I ended giving Mg to one of the wrong pt's. Nothing happened. But WHY did my preceptor stand there and watch me go into the wrong pt's room with it????

After it happened I went into the unit managers office with my preceptor and clinician. I felt so stupid. I didn't cry to them, but it was so embarrassing.