I made a medication error - Now what???

[Nurse Beth, MSN]

Dear Nurse Beth,

Oops! I made a medication error-Now what?

I made a medication error, along with another nurse, but, I am ONLY taking responsibility for my part.

Basically, I did not verify the correct dosage when the charge nurse pulled 2 pills for me from the Pyxis. The pharmacy had changed the dosage/form and now the patient only needed one pill, instead of two.

Since I am a processor, this has been on my mind all weekend. Maybe it's because it's my first medication error since having my license (still in first year after licensure); or maybe it's because I feel so stupid.

The patient was fine and even with the extra dose of pain medication, this patient was still in pain and said he thought he didn't even get any pain medication. Go figure!

At any rate, I know I deviated from my usual process of medication administration-verifying the medication, dosage, amount, etc., and I also know that on this day the error was made, there were several small fires that were happening at once and the morning medication administration time was hectic, more so than usual.

In her defense, the other nurse did say that she didn't verify the dosage either, so, we both admitted and acknowledged our own error. I'm just still processing this and want to know how do I move on from this event?

Also, in doing some very cursory research, in spite of the millions of medication/medical errors each year, (not to mention the daily ones), it seems as if nurses don't want to talk about their own experience when this happens. I'm not saying we should wear badges that say, "I made a medication error," but, sometimes, talking about these experiences with newer nurses may be valuable to the learning and on-the-job processes.

Thanks for your feedback.

---

Dear Made an Error,

First of all, every single nurse has made a medication error. You are not alone. I agree with you that talking more about our errors would help ourselves and other nurses.

You have already learned from your mistake. The most important thing you said was I know I deviated from my usual process” Right- that's how mistakes happen! Deviating from the norm. That's why airline pilots follow the exact same procedure, every time.

It would have been helpful if Pharmacy had flagged the medication in some manner with an alert to the effect that the dosage/pill had changed.

I'm curious why the charge nurse signed out medication for you to administer. That may have contributed to the error (doing things out of routine), as well as bias of authority (charge nurse must be right). You say you are only taking responsibility for my part” of the error, but the error is yours, as you administered the medication.

Pull your own meds unless it's an emergency.

I hope you've recovered by now from your first medication error, it can be traumatic. Thanks for sharing.

Best wishes,

Nurse Beth

[amoLucia]

My reading of this post leaves me questions. Maybe THERE IS a systems failure error here???

Was the other nurse the only one permitted to secure a pain med (as in narcotic) from a pyxis? Like per that facility P&P, maybe only the RN charge has narcotic access?

Was the letter writer just handed 2 'naked' pills to give by the other nurse? Like without any mfr identifying dosage blister peel? That would be a MAJOR faux-pas for the med nurse to just administer naked pills handed to her. I mean, those 2 pills could have been ANYTHING!!!

Otherwise, Nurse Beth's response does address some of the problem. But I'd need to know more.

I tend to believe the med pass situation needs to be further reviewed and revised as nec. I wouldn't be part of a system that I've asked about. I also see a possibility for 'diversion' with narcotic dispensation in that system.

[lennon33x]

As nurses, we will all make an error. But there are two major fallacies here...

1) You are justifying your med error. Never. Ever. Rationalize a med error. The only person who loses is the patient.

2) You are skirting your responsibility. If you gave the med, you have that third med check that you do at the bedside, which is to verify the med against the MAR. 6 Rights of Patient Med Admin and three Med checks (first against the order, then when you pull it, and then when you give it).

Yes, you learned a big mistake here, and yes there is probably a flaw in the system. But don't let these bigger ideals alleviate the responsibility you have to your patient.

[wolf9653]

It happens. Fortunately there were no adverse effects. All the machines i've seen require 2 people to sign out narcs, I guess yours is different. Talk to the other nurse. I wouldn't worry about her part in it. Just what you can learn from it. If you take a write up on it, you deserve it, own it. But it's far from the first time it's ever happened, so I doubt you'll get crucified over it. I would have imagined the pill would have been obviously bigger, and you should at least have been alert to that. But I guess these kind of things come with time. If something feels wrong it probably is, and it's your clue to check into it a little bit. Worst case scenario is being wrong about being wrong, and there's nothing wrong with that.

[JayHanig]

I tend to be very systematic with a lot of dogmatic routine. Why? It's not because of my successes! It's because of my mistakes. I do two things when I've made an error: 1) Own up to it. The vast majority of the time no harm is done but people will come to trust you if they know you will own your errors. 2) I spend time analyzing what happened and why it happened... then I make sure I don't put myself in the same circumstance.

I have dropped my motorcycle three times. Each time was in a parking lot at essentially no speed. Why did it happen? The first time I learned that turning the front wheel at the same time I applied only the front brake was a terrible idea. I found myself in the dirt quicker than I could type this sentence. Good thing I wore a helmet. The second time I learned never to park on a slope parallel to the bike. Once my bike starts to tip, it's so top heavy there's no stopping it... I WILL drop it. This happened in the hospital parking lot and I hit the back of my head so hard I was goofy for about half an hour afterwards. Good thing I wore a helmet. In fact I hit so hard, I bought a new helmet ($450... OUCH) on the way home. The third time I learned not to park next to anything that could damage my bike if they came together.

I know nobody cares about my motorcycle stories. The do illustrate the process though: the event, the analysis, the rules I develop to prevent the event from repeating itself. I won't even climb on my motorcycle in my garage without a helmet on now... The end result: I haven't dropped that bike again... and I've owned it for many years now. I came up with rules that I live by without exception, and they've kept me out of trouble ever since.

You don't learn from your successes nearly as much as you learn from your mistakes. Don't beat yourself up too badly over this. Any nurse who claims they have never made a med error has never administered one. Everybody makes mistakes. The important thing is to learn from them so you don't repeat them.

[travduck, BSN, RN, CNM]

I agree with amoLucia. This is partially a systems error. There should have been notification from the pharmacy for such a gross change in medication dispensed. If you went to a private pharmacy they sure would have covered their derrieres by making the error wasure that you were aware of such a change. But, as you have noted, the error was compounded by both the person who obtained the medications and by yourself as administrator of the medication. Having said that - yes we have all made errors in the past and until there is somehow invented a foolproof system invented, we will continue the occasional error. You were blessed in that there was no harm to the patient but now you know - and I'll bet you ne'er make the same mistake. Now put your energy into closing the gap in the system and in making sure that you build your own foolproof system based on what you were taught in school. And Yes I have made errors also and, so far, been blessed in not having a patient harm error on my conscience. Hang in.

[wolf9653]

Actually, I care about the motorcycle stories. But probably not a lot of other people do. I agree, don't use your front brake at parking lot speeds. it compresses the fork, which changes the head angle, and makes the bike very unstable. 2, my buddy thought he was losing his touch since he dropped his ultra, which has a fixed fairing, and a high passenger seat, and a tail trunk. I wound up renting a bike like his one day and dropped it twice, and I'm reasonably strong. Swore I'd never ride another one. Funny thing is, after I've learned my lesson and start doing things different, it becomes habit, and I forget why I'm doing things that way. And then when I try it different, I find out real fast why I don't do it that way. Same thing with nursing, a lot of my habits I've learned the hard way.

I tend to be very systematic with a lot of dogmatic routine. Why? It's not because of my successes! It's because of my mistakes. I do two things when I've made an error: 1) Own up to it. The vast majority of the time no harm is done but people will come to trust you if they know you will own your errors. 2) I spend time analyzing what happened and why it happened... then I make sure I don't put myself in the same circumstance.

I have dropped my motorcycle three times. Each time was in a parking lot at essentially no speed. Why did it happen? The first time I learned that turning the front wheel at the same time I applied only the front brake was a terrible idea. I found myself in the dirt quicker than I could type this sentence. Good thing I wore a helmet. The second time I learned never to park on a slope parallel to the bike. Once my bike starts to tip, it's so top heavy there's no stopping it... I WILL drop it. This happened in the hospital parking lot and I hit the back of my head so hard I was goofy for about half an hour afterwards. Good thing I wore a helmet. In fact I hit so hard, I bought a new helmet ($450... OUCH) on the way home. The third time I learned not to park next to anything that could damage my bike if they came together.

I know nobody cares about my motorcycle stories. The do illustrate the process though: the event, the analysis, the rules I develop to prevent the event from repeating itself. I won't even climb on my motorcycle in my garage without a helmet on now... The end result: I haven't dropped that bike again... and I've owned it for many years now. I came up with rules that I live by without exception, and they've kept me out of trouble ever since.

You don't learn from your successes nearly as much as you learn from your mistakes. Don't beat yourself up too badly over this. Any nurse who claims they have never made a med error has never administered one. Everybody makes mistakes. The important thing is to learn from them so you don't repeat them.

[Elinor]

As nurses, we will all make an error. But there are two major fallacies here...

1) You are justifying your med error. Never. Ever. Rationalize a med error. The only person who loses is the patient.

2) You are skirting your responsibility. If you gave the med, you have that third med check that you do at the bedside, which is to verify the med against the MAR. 6 Rights of Patient Med Admin and three Med checks (first against the order, then when you pull it, and then when you give it).

Yes, you learned a big mistake here, and yes there is probably a flaw in the system. But don't let these bigger ideals alleviate the responsibility you have to your patient.

She's not rationalizing or skirting responsibility -- I think she pretty clearly feels badly about it and has been ruminating. She did point out some upstream systems issues that probably contributed to the error.

Yes, you can always identify a person or persons at the end who made the mistake, and you can blame them. And yes, they made the mistake. But that is an unproductive approach, because guess what? Everyone makes mistakes. Lots of them, every day. The approach that's actually effective for reducing errors is to analyze contributory systems causes, like interruptions, no pharmacy notification, no bedside scanning, a system where a charge nurse has to pull meds for another nurse, etc.

[Kiki1970]

I tend to be very systematic with a lot of dogmatic routine. Why? It's not because of my successes! It's because of my mistakes. I do two things when I've made an error: 1) Own up to it. The vast majority of the time no harm is done but people will come to trust you if they know you will own your errors. 2) I spend time analyzing what happened and why it happened... then I make sure I don't put myself in the same circumstance.

I have dropped my motorcycle three times. Each time was in a parking lot at essentially no speed. Why did it happen? The first time I learned that turning the front wheel at the same time I applied only the front brake was a terrible idea. I found myself in the dirt quicker than I could type this sentence. Good thing I wore a helmet. The second time I learned never to park on a slope parallel to the bike. Once my bike starts to tip, it's so top heavy there's no stopping it... I WILL drop it. This happened in the hospital parking lot and I hit the back of my head so hard I was goofy for about half an hour afterwards. Good thing I wore a helmet. In fact I hit so hard, I bought a new helmet ($450... OUCH) on the way home. The third time I learned not to park next to anything that could damage my bike if they came together.

I know nobody cares about my motorcycle stories. The do illustrate the process though: the event, the analysis, the rules I develop to prevent the event from repeating itself. I won't even climb on my motorcycle in my garage without a helmet on now... The end result: I haven't dropped that bike again... and I've owned it for many years now. I came up with rules that I live by without exception, and they've kept me out of trouble ever since.

You don't learn from your successes nearly as much as you learn from your mistakes. Don't beat yourself up too badly over this. Any nurse who claims they have never made a med error has never administered one. Everybody makes mistakes. The important thing is to learn from them so you don't repeat them.

Please tell me you tipped your bike in the hospital lot after your shift:***:...

[marylou5]

Medication errors are always caused by not following protocol! Accept that you did not follow protocol. No excuses. No shared blame. You were very lucky this time..the patient was not harmed. Admit your mistake. Learn from your mistake. You can't go back. Move on and remember to follow medication protocol...If YOU don't 'pour' it, YOU don't give it..If YOU don't 'see' the med sheet/order or the bottle x3, don't give it. Don't let anyone 'help' you get your meds under any circumstances. That's risky business for many reasons...diversion for example! Being busy is no excuse for medication errors...as nurses, we are always busy. I am being harsh because you are a new nurse..only you can make sure this error is your first and last. Suck it up, deal and move on..but please don't attempt to whitewash your error with 'busy' or 'sharing blame' or 'small fires'...those are every day events in the life of a nurse ...you gave the wrong med. It is what it is! And, no, not everyone makes a med. error....only those who do not follow protocol and short cut the procedure....remember that, and it will be your last error! Don't beat yourself up...learn from your mistake..and you'll never repeat it.

[scuffles, RN]

Just wanted to say I think you are very honest writing about a medication error. Most people are too deeply shamed, embarrassed or whatever to admit to others their mistakes. We have all done it, we are all human.

[emtb2rn, BSN, RN, EMT-B]

Motorcycles & med errors. Realizing you've made a med error causes the same gut fluttering sensation as a front wheel wobble.