I made med error, what now?

TexasPediRN · Dec 3, 2007

Ouch.

I too, just last week, made a med error b/c of pharmacy. It was insulin, and the pharmacist put in 9 units instead of say, 5. The patient would have had 2 units for sliding scale for the AM blood sugar, and really only got an extra 2 units of insulin.

I felt terrible. I had to write an incident report on pharmacy..

Our PharmD was over trying to help figure out what went wrong, and made a comment like " This is why nurses need to check their orders against the chart".

Was painful.

I usually always check my orders. I dont know what happened this time.

The patient was not harmed, and b/c of the whole above situation I am more careful when it comes to meds.

The thing is, with med errors, is it teaches you to be more careful. You wont make that mistake again.

Someone once said errors occur b/c of about 8 different reasons. You were the last check, and yes, you missed it, but remember, errors occured way before that caused this error.

State the facts at the meeting. Let them know you have learned from you mistake, as I'm sure you have.

I'm sorry that a med error happened to you, but I do hope, and know, that it has taught you to be more careful in the future.

-Meghan

LiverpoolJane · Dec 3, 2007

Don't be too hard on yourself, it happens to the best of nurses. I remember as a newly qualified nurse checking a IV antibiotic with my ward manager, Drs handwriting be what it was we both misread it, and gave the wrong drug. It was still the same catagory - a cephlospore - and the doctor was saying don't worry as they were virtually identical. My ward manager setting a good example reported us and we had to go to a hearing - I sat there while the Directorate manager and the director of nursing services tore a strip off me. I sat there sobbing, I was told I could have killed someone and I could be struck off the register! It knocked my confidence for a long time and nearly left because of this.

I'm happy to report that would not happen now.

I'm a ward manager now and when one of my staff make a mistake I now how devistated they feel - I don't want to make them feel worse - I want to know what they have learnt from this. Hopefully we have a culture of being open now and nurses are supported when this happens as it is distressing. I do hope your managers are not too hard on you, I'm sure all they want to know is that you realise how the mistake happened and that you will not repeat the same mistake again.

Keep us informed of the outcome.

Jane

Dolce, RN · Dec 3, 2007

Its a good thing nothing bad happened as a result of this. I wouldn't beat yourself up too much about it--it could have happened to anyone.

If my patients are alert and oriented then I will review their medications with them as I am administering them and will ask, "Are these the same medications that you take at home?" They usually will have a couple of new or different pills that are unfamiliar to them. I can then review those medications with them. I have caught med errors this way before they happened. Sometimes the patient is the best resource of all.

Diary/Dairy, RN · Dec 3, 2007

Yup- Stuff happens - learn from it - do better next time - everyone makes mistakes! Good luck!

morte, LPN, LVN · Dec 3, 2007

i quite frankly dont see the nursing error here.....are we supposed to check every order behind who(m) ever entered it? The only prob i might see is this is not a routine med wouldnt the patient have ad a dx to support it?

fultzymom · Dec 3, 2007

There is not a nurse out there who has never made a med error. The thing to do is to take this experience and learn from it. When you are giving a medication, try to think about how it pertains to your patients diagnosis'

TazziRN, RN · Dec 3, 2007

quit beating yourself up. i do not know a single solitary nurse who has never made a med error at least once in their career. it happens. your employer is not beating you up, so don't do it yourself. learn from this and move on. if you never make this same mistake again, then there is a good outcome.

thomask · Dec 3, 2007

the stupid part of the whole thing is that I had a little nagging voice in my head that said 'hey wait a minute'... I was so busy and overwhelmed with my tasks that had to be done that i didn't listen. I have learned alot from thiswhole experience. I know that I will never enter a shift without doing a thourough chart check. I will never trust other peoples checks and I will remember that the dr's would much prefer that a med be given three hours late than for me to give the wrong one. my manager said I didn't have to go to this meeting but that it would look good if I did. I don't think I can get through it without bawling my eyes out. he said I could write something that says what happened. luckily my hospital is very supportive of their staff. we had a few very infamous errors within our hospital system that resulted in a few pt deaths. again it was pharmacy that started the error. they were extremely supportive of the nurses and they did not get fired. they were offered other positions if they wanted them or they could keep the same ones. the meeting i think is just to find out why it happened and how they can stop it from happening a again. they need to know how it got through the checks. How do you say your an idiot without making yourself look bad?

TazziRN, RN · Dec 3, 2007

you sit there and tell them matter-of-factly what happened, then you tell them, "i thought i did all my checks, and i didn't listen to my gut feeling that was telling me there was something missing."

not that this is any consolation, but you are not the only one who screwed up here, so don't try and take all the blame yourself. yes, you were the last check and it slipped by, but the mistake started with the pharmacy. believe me, the pharmacist will be talked to also.

i know you feel bad, but please don't worry. and stop beating yourself up. your facility has proven that it understands mistakes and will help you learn from them, so accept that and move on.

cmo421 · Dec 3, 2007

Chin up,head forward and move on with a new tool for learning. First,when pharmacy puts a new order in a pt's mar,it should have there name on it. Each new order,comes with a name, pt number and date/time. Written very small,and hard to see,put with my over forty glasses, but it has CMA ,a few times. I am sure not every place does this, but they should.

For every mistake I have made, it puts a notch on my belt that help me prevent another one. Humans make mistakes, given tools to prevent them enables us to make fewer.

It will shake u for a few, but u will be ok. The culture of safety of every facility is built on the mistakes of the past.

CritterLover, BSN, RN · Dec 3, 2007

i'm going to agree with the others -- don't obsess about this too much.

i was certainly more of a pharmacy error than a nursing error.

yes, you will most likely be held partially to blame, as you gave it, but you did follow proper procedure.

a few questions (mostly to help you with the meeting):

1. how often are chart checks done in your hospital? daily? every 12hrs? every shift? every 2hrs? something else? when are they supposed to be done? sometime that shift, or before you ever see the patient?

2. had a nurse signed off the order?

3. do you have a computerized mar system?

4. had the order carried over from a previous day (handwritten on the mar as a new order) to the next day? if so, who verified the mar?

from what you have said, it sounds as though this was a new order (pt hadn't received it before), yet you say pharmacy put the order on the wrong mar. that would never happen in any of the facilities where i work (though i can see how it could happen, which is the reason for the above questions). the first order is hand-written on the mar by either the nurse or the secretary. when the new mar is printed, the night nurse is responsible for verifying the new mar, by comparing it with the old one, as well as the day's orders. if that sort of process happens, then the nurse verifying the mar should catch the pharmacy error.

i ask about the chart checks because it is really impractical to expect each nurse to go over the entire chart, and verify all of the med orders, before seeing the patient. if you have 6-8 patients, and any of them have been in your facility for any length of time, it will be a couple of hours into your shift before you can see your patients, just because of your chart checks!

while i have met nurses who won't give a single med before they personally verify the order in the written chart, that generally isn't the policy. (i do see where they are coming from, but we have to be practical). in addition, that is kind of the whole point of having the mar checked/verified before use, and why we night shift nurses have to sign off on the task.

i will say, though, that to an experienced nurse, iv ig is a big red flag. not very many patients get it (i've given it once to an inpatient. i've given it quite a bit to outpatients, but it isn't a common in-patient med.) so i would have investigated why the patient was getting it. however, that isn't something i would have necessarily expect a new nurse to know. (i would expect you to look it up; but the drug books don't say "given more often as an outpatient than an inpatient.)

as for the meeting -- it's a good thing. really. they are trying to find out how this happened, and you will give them valuable information in how to prevent this kind of thing from happening again. pharmacists are human, too. and, they are just as overworked as we nurses are. they deserve to have a reliable double-check. the facility needs to know that the 5 rights failed, and need to come up with a way to fix this. that is what the meeting will be about.

and -- iv ig is serious stuff. i've had patients that were supposed to get it have bad reactions.