I made a medication error.

Nurses New Nurse


I'll give you some background. I'm a new graduate nurse, LPN for Americans. Enrolled nurse for Australians. I work at a aged care facility all high care. I've been out of school about 3months.

I got to work this morning and I'm told one of the residents has had a heart attack . I'm shocked, was nothing about it in handover. This came from a AIN. So another AIN gets the notes and reads them and says no, she went to hospital for a appointment. Ok, that was cleared up, so I thought.

Later the DON calls me into his office and says I need you to look at this incident report. I didn't give the resident mentioned above 2 of her tablets on the morning of the 22nd. One of which was a BP tablet. My heart sank, it was just the worst feeling, thinking I could have really hurt someone. I had signed the medication profile saying that yes I gave her two packets of medications when I only gave one. Don said to me, just make sure you don't sign for something you haven't given. That was it.

I in a panic went back to my wing and went through the notes, the RN documented that the meds weren't given previous morning and the resident was sick , upset stomach and feeling nauseous. BP was 86/53, RN sent her to hospital.

Hospital notes say this resident was normal when arriving at hospital, obs were all normal, though she did have a UTI and sent her back with antibiotics and antimetics. Which I'm very thankful for. (Obviously AIN didn't read notes very well)

I was really upset because I thought I had hurt someone, but I'm really angry that the RN told the AINs that were on shift that she had a heart attack. This is what came down through the grapevine. I will absolutely take that as a huge learning experience but I feel that this RN should have kept that kind of information back until they knew what was really going on. I was working that day on another wing, I spoke to this RN on the phone several times that morning, why didn't he say something to me about it? but could tell the AINs?

Maybe I'm just still shaken by the whole thing, I feel like I can't get what I should have done, didn't do, might have done out of my head. That is an everyday thing. So afraid of losing my nursing license/registration or hurting someone. I always double check my medications after each round. I still missed those. :crying2:


mistakes happen...we are ALL human.....learn and move on.....i forget my own HB pressure med at least once a week....

been in your shoes,i know that awful feeling....as one RN one told me.....

"these people are on so many meds throughout the day everyday.... a missed dose will not hurt them....just learn from it....i have been there too".....

thought that was a very nice thing to say to me....i did feel a lil better...but still...

Specializes in Telemetry.

I think first of all you need to figure out whether you made a medication error or not. Elderly people usually have several comorbidities. Remember to always check vital signs before giving BP med or HR meds. Figure out if the pt is symptomatic. A BP of 86/53 really is not that low. You need to determine first if the BP was taken properly with the right size cuff. Often times CNAs don't measure the BP correctly with the right size cuff. If the pt is thin they probably need a pediatric cuff. In the case of a low BP you can place the pt in trendelenbergs. Also you need to monitor the urine output. If you have less that 30cc/hr that's an indication that you do not have proper kidney perfusion. If you maintain the MAP above 60 you have good organ perfusion. Another thing you need to take into consideration is the pt's trends. Has their BP been on the low side or is this new?

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