I made med error, what now?

[thomask]

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!!

[dentalrda]

Hi,

I`m wondering what is a MAR?

The reason that I have been suspended was because I had gotten the meds ready earlier in the night when it was quiet. They are calling this prepacking. Because my shift is the overnight,the bulk of my work is two hours when the 4 ladies are awake and getting ready for thier programs. I do not have an hour to sit with each client while another client is seizing or another is yelling and throwing things.I felt that my safest choice was getting the meds ready at night.

I have to meet with Human resourses in the morning and DMR. Yikes!

[Babs0512]

Suspended: I don't know what to do about your situation. I understand management's not wanting you to prepackage medications, by doing so, a person is less likely to follow the patients 5 rights: right patient, right med, right dose, right route, right time. People are more apt to follow that if they are getting meds ready DURING a med pass.

I would say that when it comes time to talk with those in power, you take responsibility for the error, as you already have, try not to make excuses (clients were screaming, etc...) that won't help, that can happen during any med pass, and agree to follow their no pre-packaging policy in the future.

I applaud you for being honest, and reporting the error, as management should as well.

Good luck, keep us posted

[teeniebert, LPN]

MAR is Medication Administration Record--my manager always called them "med sheets" so if someone had said "MAR" to me before I started school I would've wondered what they were talking about.

[dentalrda]

Thanks for clearing that up!

[Keepstanding, ASN, RN]

oh sweetie, don't be too hard on yourself. you are not responsible for this. the pharmacy needs to step up and be honest about this mistake.

you hang in there and let yourself off the hook. the patient is okay and that is the most important thing. god bless you ! :heartbeat

[BlearnRN]

That is so annoying. I hate that. It just goes to show that you need to start checking up on the docs and ask them why the pt is getting the med. It sounds like the doc/pharmacist put the order in for the wrong pt. Plus the chart is not always reliable to do a med check on. I have seen different doses and recommendations for meds in the chart. On top of it all, I have seen residents carrying their notes from that day around with them,of course, with the new order on them. Just start checking up on the orders and ask them why the pt is getting that if you don't know why or if it is a new med. They should be able to explain why. I have even had a resident say " oh , I put the wrong order in on the wrong pt" and then go and change the order. ---Don't feel bad, the pt did not get hurt .

[AMarie85]

It sounds like you already have learned from your mistake... And your patient was fine... So go to the meeting and get it over with (tears and all), and you will soon be able to move past this.

I hear in nursing school all the time that every single nurse makes a med error at some point in their career... We hope we never do but we are after all human and unfortunately we are imperfect beings that work in a feild where error is unacceptable.

[Babs0512]

Not only are we imperfect beings, but the doctors, pharmacists and patients are all imperfect as well. Always report your errors, it's most important to take responsibilty and respect yourself - even if it means a reprimand.

I don't think anyone expects us to be perfect, but they (management) does expect us to make them look good. If it's your butt or theirs, your out of luck.

[dentalrda]

The meeting lasted about 20 minutes.It was with H/R and an assistant director. They asked me to tell them what happened the night and morning that I gave the wrong meds. I just gave a brief summary and answered any questions that they had.

At the end they said that this was an internal investigation and that DPPC (Disabled Persons Protection Commission ) would be doing their own investigation. I would have to have a meeting with them,most likely next week. I am not allowed to return to work until the investigations are completed.