I made med error, what now?

P_RN, ADN, RN · Dec 4, 2007

EVERYONE has made an error, if they say not then either they are lying or totally oblivious to real life.

In 1977 I gave a Tylenol #3 to the patient in A bed. It was not in his orders, he should have gotten an Empirin #3. B bed was the one who had the Tylenol #3 in his orders. I cried for hours when I realized it. I called the supervisor and wanted to resign. I remember that like it was today. No harm, no foul....now if he'd been allergic to tylenol -well different story, but he wasn't. In fact he had regular tylenol ordered.

Have you heard of the Institute for Safe Medication Practices? http://www.ismp.org/ Go to their site and read up.

I am really sorry this happened. But as others have said, this error happened, and there is no going back. I see it as a system error and not just a Nursing error. It is a hard, hard fall and it hurts a LOT. Go to the meeting, I would.

Never, never forget. You are a NURSE, but you are also a living, breathing human being and we are all fallible.

Agnus · Dec 4, 2007

I am a new nurse, and I made my first med error. I gave a pt IGg who wasn't supposed to get it. I did my five rights. I checked the med against my mar. I confirmed right dose right pt right route right time. It was all good. I even called pharmacy!!! I had no idea how to give or titrate this med. I watched my pt carefully. I made sure her pressures etc were all wnl. The problem was that pharmacy had put the med in the wrong patients MAR!!!! the reason I made the error was because I did not look for the original order in the chart. Had I done my chart check like I was supposed to I would have caught it. I didn't. I came in the next day and was told what I had done. fortunately the patient is fine, and she had no ill effects from the drug. But it could have killed her. I could have walked into work and found out that someone was dead because of me. how do you cope with that? how can I go in and not have a panic attack? I am not getting fired although i can't say i would blame them. I am absolutely devastated( i cried nearly all shift) and now I have to go to a root cause multidisciplinary review thing and explain why I am an idiot. how do I explain that?!!! well thanks for listening!!

Pt was unharmed. So let that part go. I believe you now know how to prevent repeating this mistake and you will.

Welcome to the real world of nursing. You now have your first scratch on your shinny new car now drive on.

Agnus · Dec 4, 2007

One more things (((HUG))) I always ask myself why this patient is getting this med. If I don't know then I proceed to find out, because these kinds of errors do happen.

Understand you are human and this is a shared responsibility though Not to minimize your responsibility in it.

Scrubby · Dec 4, 2007

Hope you feel better soon and they aren't too hard on you at the meeting.

In my grad year i made two drug errors, lucky for my patients that they weren't serious. I gave the wrong insulin (even though another nurse checked the order and vial with me) and i also missed a dose of methadone and my patient was in extreme pain all night.

I can remember how i lost my confidence for a while after both incidents

Virgo_RN, BSN, RN · Dec 4, 2007

There are many shifts where I am too busy to look at the actual paper chart. I'd like to think a med error like yours would result in process improvement. For instance, at the facility where I work, every time new orders are entered into the computer system, they must be checked against the chart by a nurse. It can be a nurse assigned to the patient, or another nurse on the unit who has time. It doesn't matter who does it, so long as it is a nurse, and the paper chart and computer record are checked against one another. The order is highlighted blue in the computer until a nurse does the check, then it goes to the regular tan color. This alerts the nurse administering the med or providing the treatment whether or not the order has not been double checked against the chart. This way, every single order in the computer is checked against the chart, and errors can be caught. We once had a blood transfusion put into the computer on the wrong patient. It was because of this procedure that the error was caught and the right patient got the blood.

oneLoneNurse · Dec 4, 2007

Nothing, move on, learn from the experience. What went wrong in your check-list? Prior to giving a med there is a process I go through, to check the six rights. The sixth in my mind being the right reason, but have heard others.

Thing is, you didn't hurt anyone. And from what you posted I don't think you would have, since from your posting you stated you monitored the patient during the administration.

As the posting above this one states change/correct/update your nursing process.

dentalrda · Jun 28, 2008

Hi,

I hope I don`t get in trouble for asking a question from this website.It`s the only place that I could find that could relate to something that had happened to me.

I am an over night staff at a group home.I have been working there for 10 years.I have never recieved any warnings or been in any trouble. I have always been told that I am the best employee at this house b/c I always go the extra mile.

I have been working alone for ten years on the overnight. I help the four ladies get up and off to their day programs in the morning. I also dispense their meds. One client alone has 17 pills to take in the morning. The other three have less but still many. Since there is yelling and screaming from the ladies in the morning,I sometime would get the meds ready the night before. I was doing my 5 rights and being OCD careful about it. I never had any mistakes during those years.

Recently,one of out clients left(the quiet one of course)and she was replaced with a nearly paralized client. Because of this,an extra staff has been added and for many months I was working with relief people until someone could be hired permanently. So my workload had basically doubled and I`m also trying to train relief people who for the most part are useless.

One morning this week,I gave some wrong weds to the wrong client(it was a horrible night and equally horrible morning.Lots of yelling/demanding and walking around in urine). She took two Felbatol 1500mg and two Kepra 1200mg. I immediately called my manager who told be to call poison contol. P/C said that there was no interactions but to watch the client for sleepyness.

The clients doctor was called also who said to bring her to the ER as a precaution. They said that she would need to stay overnight to have her B/P watched.She basically was fine.My manager did a supervision with me and basically told me that I cannot prepackage meds. My manager did everything she could do to keep me from getting any type of warning. We thought everything was all set until 8pm that night. I got a call from my manager who said that the agency had suspended me pending an investigation. I was crying so much!I felt bad enough making the mistake,I feel like they are raking me over the coals. I have been in this field for 15 years (without a med error) and I have never seen anyone pass meds like we are taught in med class. Especially when we are working alone.

I have no idea what to do now. My manager gave me the number of the woman who is in charge but I was crying so much last night that I never phoned her. I take full responsibility for the mistake but I don`t feel that I deserve this.I am 47 years old and have never been in any type of trouble at any job. I have never been fired.

Any suggestions? Should I get a lawyer?

Thanks

teeniebert, LPN · Jun 28, 2008

Hi there! I worked in an AFC home for 3 years, resigned when I got accepted to nursing school a couple months ago. Anyway, your best move here is to call the person in charge of the investigation. If you took action as soon as you discovered the error, followed your agency's policies, and filled out the appropriate paperwork (documented on the MAR and progress notes, completed an incident report, etc.) you've done all you can. Talk to the investigator and find out what they need from you. If you are interviewed or asked for a written statement, be truthful in your answers. If there was someone shouting near you while you prepared meds, say so. Be descriptive, not evaluative ('Client X walked through the room shouting "I hate your guts!"' as opposed to 'Client X was yelling at me, trying to pick a fight.'). Don't feel like you have to explain yourself, just say what happened.

You have a lot more experience in this field than I do, but I can relate to your feelings of frustration. In the home where I worked, I was often one of 2 staff (not per shift, working in the home AT ALL), the other being the live-in supervisor. We had other staff come and go but rarely stay long, due to the nature of the field. You get used to working alone after a while. Add another staff to the mix (which is supposed to lighten your workload, right?) and it all goes to h*ll because the normal routine is disrupted...then you can't restore order because the new staff doesn't know the clients and ends up reinforcing the behavior that was put on an extinction plan...

I hope the investigation doesn't result in major disciplinary action for you; it may be that they have to investigate med errors according to policy but the end result will be a verbal warning. Keep us posted!

mc3, ASN, RN · Jun 28, 2008

Ok, so nobody yell at me,but, are you supposed to check each med against it's original order each time OR what's listed on the MAR?

mc3:paw:

dentalrda · Jun 29, 2008

Yes,this is what I was taught in med class. As I`ve said,I am not a nurse or even a CNA. I work(ed) alone and had an hour and a half to get four clients ready and out the door in the morning. It would take me at least an hour to do the 5 rights and properly give each med to each client. The only quiet time I had was when the ladies were sleeping.I did it correctly as I was taught but instead of giving it to a client I would put it into a cup to use in the morning. I have not had any errors in 15 years and also,I have never seen any other employee giving the meds the "proper" way to the clients. It`s like a little secret amoungst group homes maybe?

Nothing was done purposelyto cause any harm to the clients and I felt that this was the only safe way. I took the correct steps after the error and never tried to hide the error.

Anyone else been suspended for an error?

Babs0512 · Jun 30, 2008

As has been clearly stated, we've all made med errors. I can totally relate to how you are feeling - however, the error started with pharmacy. I cannot believe each nurse is expected to take her MAR on EACH patient, then go through the chart and make sure that the charge nurse and unit secretary transferred the order correctly to the MAR.

OR, if the MAR comes up from pharmacy, are you really expected to go through all your patient charts to check pharmacy's checks?

Sounds like a very time consuming and inefficient system to me. You did your patient five rights, according to you double checked, and you administered the med. Sounds like the issue is primarily with pharmacy, not you.

I cannot imagine having say 6-8 patients, and before starting my day with them, having to check all the charts to make sure ALL orders (to include treatment orders) were transposed correctly. That would make all meds late and even less time with the patients.

Don't sweat the small stuff dear. Learn from the mistake, stop beating yourself up. Don't lose confidence in your ability. Do what you can to see that your (small) part in this error doesn't happen again.

Good luck, God Bless

mc3, ASN, RN · Jun 30, 2008

As has been clearly stated, we've all made med errors. I can totally relate to how you are feeling - however, the error started with pharmacy. I cannot believe each nurse is expected to take her MAR on EACH patient, then go through the chart and make sure that the charge nurse and unit secretary transferred the order correctly to the MAR. OR, if the MAR comes up from pharmacy, are you really expected to go through all your patient charts to check pharmacy's checks?
Sounds like a very time consuming and inefficient system to me. You did your patient five rights, according to you double checked, and you administered the med. Sounds like the issue is primarily with pharmacy, not you.
I cannot imagine having say 6-8 patients, and before starting my day with them, having to check all the charts to make sure ALL orders (to include treatment orders) were transposed correctly. That would make all meds late and even less time with the patients.
Don't sweat the small stuff dear. Learn from the mistake, stop beating yourself up. Don't lose confidence in your ability. Do what you can to see that your (small) part in this error doesn't happen again.
Good luck, God Bless

That's what was I was questioning, as well....

mc3:paw: