I made a potential deadly transcription error


The night before last I was transcribing orders in an AL facility. I wrote an order for an antibiotic in the wrong patient's MAR. The med tech came for it and the wrong patient received the medication from the back-up supply. It was not caught until a second nurse double checked the orders 12 hours later.

I was only made aware of the error 24 hours later by the aide talking about a patient receiving the wrong medication. My heart immediately sank. I am devastated that I could have made a lethal error. Thankfully, the patient does not have a Sulfa allergy and has had no ill effects.

I am so relieved the patient was fine. I am saddened that the nurse who noticed the error is the one I took over for. Is it common not to inform someone of a such a severe error? Was she afraid of my reaction? Why would anything like that be her concern when I needed to be informed for patient safety? Had the aide not mention anything to me, I very well may not have been informed until I received the transcription error several weeks from now.

I am beside myself and I cannot comprehend how I let this happen.


7,735 Posts

Specializes in retired LTC.

Mistakes DO get made. Fortunately, there were no ill effects to the pt.

I wouldn't be too hard on the other nurse as it may have just slipped her mind because no harm done. She likely would have told you. Not knowing your facility, you prob should have been involved in writing up a med error report.

You do need to do a serious review of how you made the error and what you can do in the future to avoid similar occurrences. It's a good thing that there's so many systems of checks & balances in places to safeguard for more errors.

Esme12, ASN, BSN, RN

4 Articles; 20,908 Posts

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 43 years experience.

((HUGS)) Mistakes happen. Yes you should have been told...but unlike the present mentality of punitive action this should be looked at as a learning experience and how to not make the same mistake. Is it a systems issue? What can be imporved upon to prevent this from happening again.

It is scary but I'll bet you won't do it again....((HUGS))

Ruas61, BSN, RN

1,368 Posts

Specializes in MDS/ UR. Has 41 years experience.

It may not be her place to inform you of the error. That maybe managerial prerogative. It is not good that the CNA knew and is discussing it in the open.