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.
