I made a med error

Nurses Medications


Hey nurses,

I just need to vent a little. I'm not sure why this medication error is hitting me so hard as it isn't the first I've made and definitely not the last. I have never made the same type of error twice and this is no exception. I think I may be frustrated because of how the doctor belittled me for the error as if I were incompetent.

Here's the story:

My patient had a home medication for metoprolol in her room. Per our policy patients cannot take their medications. I looked on the Mar and there was no order. This being night shift I called the on physician twice with no answer so I then called the attending. The attending gave me a verbal order for the medication, I proceeded to put the order into the mar. I give the med.

Three hours later:

pharmacy calls me and states, " the med ordered is not the same as the pt takes at home. " What?? I re look at the mar then look at the med rec...I had put in the wrong drug. The same dosage and frequency but the Medication was a different form of metoprolol. I about cried. I got my big girl panties on and assessed the patient. She was fine her bp was good and she said she felt normal. I called the on call doctor...

He asked me in probably the rudest tone you could muster, "SSo you thought it was okay to call me at 1130 at night to ask me about a blood pressure medication?"

Well no...i am calling about the error.

"You just aren't getting it, I find it odd you don't understand why it isn't okay to call someone who is sleeping about a blood pressure medication."

Erm...The patient is stable and I read off her vitals.

He just kept asking me why I called him. Eventually I gave up trying to explain what happened and stated it was a medication error between these two medications the patient is fine and because I called you I get to write in my note and incident report that you were informed.


Damned if you do, damned if You dont. I just wish it hadn't of happened and glad I am able to learn from my mistake. Thanks for your continued support in my sanity ;)


85 Posts

Specializes in Med Surg.

You did the right thing...what a jerk!

chillnurse, BSN, RN, NP

1 Article; 208 Posts

Specializes in Internal medicine/critical care/FP.

It won't hurt them. Not much diff between them. I change everybody admitted to the hospital to our version since I don't think pharmacy carries both. Don't sweat it lol

TriciaJ, RN

4,328 Posts

Specializes in Psych, Corrections, Med-Surg, Ambulatory.

Uh, he was the ON-CALL doctor, right? And he was surprised when his phone rang? And he didn't know that everywhere in the free world you have to call the doctor when any kind of error is made? :banghead:


642 Posts

Specializes in Med/Surg/ICU/Stepdown.

One thing I have struggled to learn as my training wheels come off (or as a "new nurse") is that I cannot take a doctor's ranting and raving personally, especially if it is in relation to something I am supposed to be doing, like notifying them of a critical value or a medication error. Whether or not they realize it, they will want to have know, and had you not told him, the outcome could have been much worse (patient harmed, disciplinary action, etc).

Water off the duck's back! Patient advocacy sometimes means getting the shaft from the physicians. Ultimately, you're just doing your job. Reporting a med error to a cranky doc doesn't make you incompetent. Thinking that he can speak down to a nurse for following policy makes him look pretty ridiculous. Next time, I would inform him that it's facility policy that he be notified, and document his response (objectively, that is).

You did the right thing!

jadelpn, LPN, EMT-B

9 Articles; 4,800 Posts

Oh, my.

"And you think it ok to belittle me for following policy?"

There are 2 different types of metropolol. One is long acting, one short acting. Our pharmacy is nuts about using "tartate" or "succinate" because of errors regarding this. (

Ok, so moving forward, I would relay this information to your charge nurse. Perhaps then you can get a second opinion on if in fact it warrants a call to the MD. If the bottle was in the room, I would be hesitant to give a dose. You really have no way of knowing if the patient out of habit took the med or not. And it could be clarified and given with the next dose, per your facility policy. There is however, LOTS of what-ifs with this, and if the patient were unstable and/or hypertensive than it would mean something different entirely.

Bottom line, use your resources and pass this stuff by your charge. With that being said, how you were treated was uncalled for, rude, and just poopy of the doctor. That he doesn't want to be called is not your issue, and unprofessional of him to make it so.

chillnurse, BSN, RN, NP

1 Article; 208 Posts

Specializes in Internal medicine/critical care/FP.

Oh I thought this was debating brand name vs not brand name. My bad lol. Yeah those ones r pretty diff as u stated well

Esme12, ASN, BSN, RN

1 Article; 20,908 Posts

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

If I had a dime every time I annoyed a MD by calling them.....I would make Bill Gates look like a pauper.


127 Posts

"Policy states MD needs notified. I am letting you know.Would you prefer I call you at 2am when my paperwork and assessments are completed to notify you? " Don't take it personal. Some are just stinkers and need reminded.

Congratulations, you just reinforced the fact that you are an actual human. Anyone who tells you that they have never made a med error is an excellent buyer for the Brooklyn Bridge:yes:

We live and learn. And part of learning is not doing absolutely everything impeccably correct every time, all of the time.

kiszi, RN

1 Article; 604 Posts

Personally I would have probably waited till morning to get the med ordered if her vitals were stable. Still, he had no right to speak to you like that. Jeez, it's not like you called him at 3am.

Just curious. Does your policy have any time frame to notify the on call doctor ?

Could it have waited until morning? Especially when it is the same med, just a different form and the patient was not experiencing any untoward effects.

Please stop beating yourself up,Dr. Jerk did that for ya .. all by himself.

+ Add a Comment

By using the site, you agree with our Policies. X