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)

[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.

Reply # 2 to your post.

I do concur with your advice about malpractice insurance.

PLEASE PLEASE PLEASE PLEASE

FOR THE LOVE OF DOG =^..^=

BUY YOUR OWN -- YEP, THE ONE YOU PAY FOR -- MALPRACTICE INSURANCE

That is all. Thanks.

The cost is usually less than $3-4 per week. Or a latte/salad/sandwich at the deli (you get the idea). Just do it.

Protect yourself and your future. The hospital will not give two flips about you and will sacrifice you in half a heartbeat if need be. Protect yourself.

Best money you can spend.

ONWARD INTREPID ANGELS.

:angel:

[SmilingBluEyes]

I did this in my first year of nursing. Wrong narc, similar but NOT the one ordered. I sucked it up, called the MD and wrote up a report.

What happened to me? NOTHING. The MD was not happy but he understood I made a mistake. Fortunately, the patient was not allergic and did not have an unfavorable reaction. I was lucky.

Own it, write up the report, talk to the MD and your charge nurse or manager.

Then learn from it and move on.

[Kooky Korky, 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:

Did it make the doctor a better doctor? I would do what you did - never take another VO or TO either, without a witness. VO for doc's "convenience"? Never. Doc can just take a moment to write it down.

[Kooky Korky, BSN, 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!

Not an excuse, but when we volunteer, we often pay a price.

Unless you need the money, don't help when they are short-staffed. It's not your problem to fix staffing.

[BeenThere2012, ASN, RN]

1. It's completely unrealistic to get through an entire decades-long nursing career without a single error. Anyone who thinks they did is self-deluded.

2. Most med errors are systems errors. This means there were more factors at work than just you being inattentive. For example, you said there were 2 similarly-labelled narcs stored in close proximity. That is an error waiting to happen and pharmacy needs to address that. Distraction is another factor and some facilities have implemented ways for nurses not to be approached or bothered while administering meds.

3. Many facilities become concerned when there are NO reported errors. That is because it doesn't mean errors aren't being made, they just aren't being reported. Not reported is a bad thing because systems problems can't be corrected and they don't want their first inkling to be in the form of a lawsuit.

OP, you absolutely did the right thing. I hope your employer also does the right thing. If they give you any grief over this, they are doing the wrong thing.

Triciaj....I agree with all you said except..

In all my years, I've only seen a system changed in response to a med error 1 time. I agree that reports are supposed to help reduce factors that contribute to med errors. However, I've only seen it done once involving using nanograms. Those orders were eliminated. The fact that we are rushing or drained from constant pressures and loose focus after many hours of non-stop demands will not change as long as staffing ratios stay the same. Just my opinion.

[BeenThere2012, ASN, RN]

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.

We all did this years back before computers.

[BeenThere2012, ASN, RN]

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.

Oh so sorry! I know the feeling. One point to you....WRITE EVERY DETAIL YOU CAN THINK OF NOW OF WHAT HAPPENED.

I hope you are not going to be harshly punished. We all learn big from these things and we all can relate.

[BeenThere2012, ASN, RN]

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:

I have no quote for you in writing other than to say it happened to me. My license was not revoked but put on probation AND other factors were involved like a second nurse who double checked me as this was a high alert medication and then through me under the bus to keep herself from being held partly accountable. She outright lied. She was one of the "darling" nurses on the unit and others knew I had just come off pain Meds for a chronic medical problem. Assumptions were made WRONGLY, and I had no power to stop the rolling bus as it approached. I didn't even know the bus was rolling until discovery was presented years later. Let me tell you, that was a SHOCKER! It nearly ruined my life as I knew it and has changed me forever.

I finally am nearly off probation and I still cry whenever I think about this whole situation even though it is nearly over. I don't trust ANYONE I work with any longer. I am bitter about this beyond belief. My opinion about nursing has been severely damaged and yet I still love my profession, but hate the way it has evolved.

We are so defensive and protective we don't support each other the way we used to do. We are so stressed to the max to do our work, even the basics, that we can't help each other the way we used to do as well. Believe me, there were MANY factors that contributed to my case that I had no control over, but often that IS the case.

Now...I push forward to continue to provide the very best care possible. I learned so

Much from this experience, including compassion for others. I know now that mistakes do and will happen in every nurse's career. If someone says they have never made a mistake because they follow all the "rules" every minute of their practice...they are lying. I was and still am a very compliant nurse with regards to safety rules and policies and yet, here I am. S**t happens!

Full disclosure... I made 3 med errors in 7 years. A lot of "systems" issues contributed...I was not the only one. The fact that I was a compliant nurse and reported all errors made me look like I had a pattern. One wasn't even my error, but I failed to catch another's mistake as did 3 other shifts. One error I didn't know about until it was caught by the computer reporting system by pharmacy. Therefore I say, many errors are made and not caught, so if you think you never made an error in years of nursing, you might be wrong.

Didn't intend to go on this long, so I'll just end it here.