I made a medication error. What will happen to me?

[whyohwhy]

Hi fellow nurses,

I self reported a medication error. While administering a scheduled narcotic, an opiate, I accidentally pulled a different, similar dosed opiate. The packaging on the two was very similar and there were many distractions at the time. As soon as I realized an error had been made I notified the MD, monitored the patient, wrote notes, filled out an incident form, etc. In all my years as a RN, I've never been involved in any incidents like this. How worried should I be here? (The patient was fine, though I know that does not mitigate the Med error)

[dumbnurse, ASN, BSN, MSN, LPN]

You reported it, monitored your patient and completed all the necessary paperwork. That is all they can ask for. Transparency is where they are all trying to get to. And like the other poster said, "Take a deep breath"

[bgxyrnf, MSN, RN]

(The patient was fine, though I know that does not mitigate the Med error)

It most certainly does mitigate the error.

The fact that the patient was fine means that on the broad spectrum of med errors, from very minor to very serious, your was in the lower third IMO.

Not all med errors are equivalent and the fact that there was no harm at all is mitigating.

Sure, you made a mistake... and it's not OK... but it DOES happen... and nobody got hurt.

[amzyRN]

Do you have malpractice insurance? Every nurse should have it. I wouldn't be worried about it unless the patient was harmed, which would be different. Everyone makes mistakes and you did the right thing to report it.

[Medic_to_BSN, BSN, RN]

One thing I've never quite understood about med administration computerized programs such as you describe ... you scan the patient wristband (beep!) and then the medication bar code (beep!), or if you were wrong - oops! - It's exactly the same beep. Sure, some red-colored ribbon might pop up on the computer. And that computer is usually to your back as you are facing the patient with the computer screen behind you. So, the beep did no good (it is the same if you are right or wrong), and the computer didn't do much good unless you turn around (not a natural action for the nurse administering the medication).

So, I asked one time why it doesn't make a different noise (think "buzzer") when the med and the patient don't match. I was told (and this seemed reasonable) that ... "Well, how would you like to be a patient and hear a buzzer go off as if the nurse was wrong in a game show?".

I get that, but if I was a patient, if it prevented the error, I would be pretty okay with it.

I simply don't get the concept that it is going to make the same noise (on the second scan) if you are right or wrong. What is the point of a noise at all, in that case, except to confirm you made a scan?

FWIW, I am entering nursing school now after a decade in quality improvement, and I'm pretty sure I'm in for a "rude awakening". The nurses were almost always the most valuable members of my teams, because they usually knew exactly what was wrong and mostly how to fix it.

[mtmkjr, BSN]

One thing I've never quite understood about med administration computerized programs such as you describe ... you scan the patient wristband (beep!) and then the medication bar code (beep!), or if you were wrong - oops! - It's exactly the same beep. Sure, some red-colored ribbon might pop up on the computer. And that computer is usually to your back as you are facing the patient with the computer screen behind you. So, the beep did no good (it is the same if you are right or wrong), and the computer didn't do much good unless you turn around (not a natural action for the nurse administering the medication).

So, I asked one time why it doesn't make a different noise (think "buzzer") when the med and the patient don't match. I was told (and this seemed reasonable) that ... "Well, how would you like to be a patient and hear a buzzer go off as if the nurse was wrong in a game show?".

I get that, but if I was a patient, if it prevented the error, I would be pretty okay with it.

I simply don't get the concept that it is going to make the same noise (on the second scan) if you are right or wrong. What is the point of a noise at all, in that case, except to confirm you made a scan?

FWIW, I am entering nursing school now after a decade in quality improvement, and I'm pretty sure I'm in for a "rude awakening". The nurses were almost always the most valuable members of my teams, because they usually knew exactly what was wrong and mostly how to fix it.

I see your point, but all my cues are visual, what the screen is showing. I never scan with my back to the screen... The scan is simply capturing the data.

When I see the red ribbon it gets my attention well enough, and I don't usually have the screen facing the patient because I think it's better that they not even see the red ribbon, of wrong entry, let alone hear a disconcerting "bzzz" of wrong med/dose or whatever.

I also don't give the med without first seeing it scanned correctly into the MAR as the final safety check.

I'm still wondering how the OP managed to give wrong narcotic if it was electronically scanned...

[Medic/Nurse, BSN, RN]

OP, I think you will be just fine. I cannot imagine a circumstance that becomes punitive over the error you made.

You cared for patient. No harm. You accepted responsibility. You reported.

I bet you don't make mistakes going forward.

All good.

Mistakes happen. To us all.

Good Luck!

:angel:

I have always learned more from the things that went wrong, sideways and all to h*** that I do when things go right. I pick them apart and find the points (trust me there are usually multiple "points" where sound clinical decision making been the rule or outside factors been managed things could have been different) and challenge myself that the future will NOT include those type mistakes in my practice.

Some things I learned from near misses (not drug, but clinical practice, I'm sure meds were involved)

• Yes, pedal pulses that are not equal can indicate impending rupture of a triple A. Correlate clinically I actually have found 10 or so with this as a sign. All made it to surgery pre-rupture .

• Yes, a 70+ year old that is not feeling right and is puking for no reason is having a big inferior MI till I can prove otherwise.

• Yes, if my Gestalt tells me that there is abuse going on with a patient or weapons may be being brought in - getting actual LEO's there quietly and quickly can be lifesaving. It's not being judgement all, it's proactive. Let the cops get a cup of coffee, and hang out.

• Yes, be prepared for deteoriation of any patient with altered mental status. Assure that family gets time with patient. Bad things can happen fast. Like death.

• Yes, if you look across the room and someone (baby to elderly) looks really sick, they are probably really sick. Keep in mind very young, old and chronically ill have diminished reserves.

• Yes, while death is very still and I believe in moving fast, I also know that deliberate movement is essential cause death is a trickster and comes for everyone. I intend to play purposeful defense.

:angel:

I made a med error. I still have a license. There was no discipline. I beat myself up plenty.

It changed the way I practice.

I filled out an incident report. Accepted full responsibility for the med error. Wrote down how I would prevent any future error from happening.

It was a dumbbutt thing I did. Truly.

We were expecting 2 ambulances on a trauma alert. We were already busy. I had the 2 trauma rooms and 2 side trauma (minor) rooms (supposedly I would get help from charge or float, but you know...). I do what I needed to, when all failed I could do what I needed and then start giving directions to others. Anyway... No big deal.

This patient had been placed in my side access trauma room as they were a quick "nothing" patient per triage. Right? Yay!

It was a healthy adult patient in their 30's with isolated complaint of extremity pain or something similar. There were no concerns requiring labs, IV fluids - we were sending them to radiology for a quick X-ray and I had already assessed, the doc had chart & had assessed.

He put the order in for X-rays as I was busy with something else & called out to me in passing "would you have a minute to give that patient a quick shot of Toradol" -- I get a verbal order to give some Toradol IM as radiology transport is waiting to take the patient.

I pop over to the Pyxis pull Toradol 60mg IM and give the injection and off they go.

When I finally track down the chart the order is for ----

Toradol 30 mg IM

***** I've never given 30mg IM since I've been here given to a healthy adult. Now keep in mind this was IM not IV.

But, I f'ed the goat on this one. I knew there was no chance of harm on the error vs. having given the written dose, but I took a verbal Oder BECAUSE I trusted a doc, but I owned this one. Big time. It's on me.

I should have stopped the circus. Set it down.

I found the order and asked the doc if perhaps he meant to order IV, and repeated the verbal order for giving a shot of Toradol IM - did he really mean 30 vs. 60 since it wasn't an IV dose. Then I told him what I did. He threw me under the bus on it. Okay. It was a verbal order. It was stupid that I followed it without clarifying specific dose. I had given Toradol hundreds of time and had never given 30mg IM to a healthy adult. Oh, well. First time for everything. Funny thing, I never saw another order for 30mg IM Toradol afterwards. But, still ... 100% my fault. How could I be so STUPID.

Really, not a life threat. Should have confirmed dose. Not just Toradol IM.

I am better than that. I know better. However, I did not do what I was supposed to.

I was a traveler, but I had been there 6 months and was well liked (I thought) and I liked it there (they asked me to come on as staff). But... You never know. And yes, they asked me to stay even after the error. No, I did not stay.

Even when I looked for the chart, it took me ~15 minutes to locate it and it was in the back ER section for no real reason.

Knowing I needed to get the patient to radiology and out of my trauma area contributed.

Following customary doses ordered contributed as well. I was a dumbbutt.

And NEVER taking a verbal order became a cornerstone of my practice going forward. Period.

Anyway. Onward.

It didn't kill the patient.

It didn't kill me.

It did make me a better nurse. So much better.

:angel:

[Alex_RN, BSN]

I used to work at a busy LTAC with mostly paper charting and no Pyxis. Narcs were in a locked cabinet with a clipboard. If someone grabbed the wrong but similar drug, like a Percocet instead of a Norco, we would try to get a one time order from the MD to cover it and no one would acknowledge the med error because everything was accounted for. That whole job was a slippery slope.

[Medic/Nurse, BSN, RN]

One thing I've never quite understood about med administration computerized programs such as you describe ... you scan the patient wristband (beep!) and then the medication bar code (beep!), or if you were wrong - oops! - It's exactly the same beep. Sure, some red-colored ribbon might pop up on the computer. And that computer is usually to your back as you are facing the patient with the computer screen behind you. So, the beep did no good (it is the same if you are right or wrong), and the computer didn't do much good unless you turn around (not a natural action for the nurse administering the medication).

So, I asked one time why it doesn't make a different noise (think "buzzer") when the med and the patient don't match. I was told (and this seemed reasonable) that ... "Well, how would you like to be a patient and hear a buzzer go off as if the nurse was wrong in a game show?".

I get that, but if I was a patient, if it prevented the error, I would be pretty okay with it.

I simply don't get the concept that it is going to make the same noise (on the second scan) if you are right or wrong. What is the point of a noise at all, in that case, except to confirm you made a scan?

FWIW, I am entering nursing school now after a decade in quality improvement, and I'm pretty sure I'm in for a "rude awakening". The nurses were almost always the most valuable members of my teams, because they usually knew exactly what was wrong and mostly how to fix it.

I haven't worked in the hospital as staff in several years (other than doing limited education and consulting) and let me assure you of one thing - nurses are sharp. Write that down.

Systems are rarely designed by nurses for nurses, hence the disconnect. They are designed by academics or management, if a nurse is involved it is never a nurse "end user" that is involved from inception.

Likewise few documentation and QA/education, inventory or safety systems have been designed by medics and are widely used.

Management in healthcare stays on quest to (improve processes) reinvent the wheel and lots of resources (wasted!) go into the same. Guess what? Wheels will still have to be round to roll! -- that fact seem to be lost on consultants, developers, etc. The vexing part is safety that works is usually simple. The best processes are simple, clearly defined, easy to follow and include more fail-safes, less feel-goods (or the exact opposite of what is being used and more to come/in development).

Another thing, this is not an idea that is new or lost on most practicing nurses. Most nurses could improve systems and find these improved systems cumbersome and less than intuitive. The big question in systems should be "how have patients benefitted" and if no real benefit can be defined, it clearly doesn't work.

Scanning meds or more steps in checks rarely catches/prevents a mistake. It does check the timeliness of the nurse giving the dose of certain meds. It does check the meds for accuracy, but won't prevent an error in bedside scan, just generates an error administration report. It generates charges for billing. It helps pharmacy with stocking and inventory. Understand what it is really designed to do. Prevention of errors? At what point? Mystifying.

Yeah, you will be in for a rude awakening in school (and beyond). Pro tip - prolly best to keep your head down and mouth shut through school, at least till you get that license.

Common sense in healthcare processes is very uncommon.

:angel:

Oh yeah, a buzzer on the wrong med wouldn't bother me at all either. A simple "I have to double check this" would be sufficient from the nurse. Boom. Onward.

[anashenwrath, ASN, RN]

As others said: not sure what your working environment is, but I think you'll be fine.

I remember when I made a narcotic error. And I didn't catch it, my supervisor did the next day! I was horrified, mortified, and thoroughly convinced I was going to be drawn and quartered. I can't even describe the SHAME I felt as I sat in her plush office, mumbling about how the error had occurred when I picked up an unfamiliar shift to cover short staffing. (Like that was an excuse)

I didn't get any sort of reprimand except some education and a reminder not to rush.

You went above and beyond. You sound like an excellent nurse. Be at peace!

[JBMmom, MSN, NP]

Had I read this before yesterday I would have joined in the chorus of- don't worry you'll be fine, no harm done just learn. Then yesterday morning I made a mistake of my own. Very ill patient, likely a lawsuit for the hospital. I scanned a drip and then accidentally programmed the pump for standard dose rather than high dose, so the drip was 10x too much for an hour. Thankfully I started it only a hour before shift change and then we caught it during handoff. I was mortified, and my first thought was, what if I had done that at 7pm and it ran for 12 hours?! How could I have rushed that much through setting it up? Felt like an idiot. I filled out the paperwork, reported it to the physician (who gave me a hug instead of a reprimand because she said I was going to beat myself up far more than she would anyway), and I'm trying to move on. I only thought about it about three times an hour today, probably 10 times an hour yesterday. Told my husband, my kids, my parents, I'm a bit stuck on it. I'll get through it, you will too, and so will our patients. All the best, I think I know how you feel, and it sucks.

[EdieBrous, BSN, MSN]

Stop giving her misinformation. Nursing boards DO discipline licenses even for unintentional errors and when patients were not harmed. Make sure you are insured with your own policy & get actual legal advice from someone who practices disciplinary defense in your state.

[Medic/Nurse, BSN, RN]

Stop giving her misinformation. Nursing boards DO discipline licenses even for unintentional errors and when patients were not harmed. Make sure you are insured with your own policy & get actual legal advice from someone who practices disciplinary defense in your state.

Please post a link with citation of these unintentional, no-harm, self-reported medication errors you cite that result in BON DISCIPLINE to the nurse.

It's not that I don't believe you, I have no reason not to. I'd really like to see this on paper.

You have asked the AN community to STOP telling everyone "you will be fine" as its wrong and you have proof. Please share. Let's blow this just culture all to hell.

Thanks.

:angel: