I made two med errors in one day.

[geekgolightly, BSN, RN]

I was a nurse for two months before I took a year off to care for my new baby. I am back at work now in a new facility, in a new state, and have been on the floor orienting for two weeks. The last shift I worked, I made TWO mistakes. Both med errors.

I wrote down 159 instead of 129 for blood sugar after hearing the PCT say "159," and did not check to make sure it was that number. I gave 4 units reg insulin based on that. Pt was fine, on decadron adn eating up a storm so her blood sugar actually went up and stayed up all day, so it definitely didn't harm her to get the extra 4 units that day. Still, I was so shaken from this experience. I cried and my preceptor felt so sorry for me, he kept reassuring me all day that I was doing well. Whcih I knew came from feeling sorry for me rather than being proud of me.

I also, took from the PYXIS reglan and DHE and gave the reglan, but did not follow up with the DHE ten minutes later. It was 7pm, shift change, I was giving the med to a patient I was not giving report on (it was offically my preceptors patient, but I said I would give the med) so although I told my preceptor that I put the DHE in the patients med cart, I didn't tell the night nurse that information. She left a message on my machine which I didn't get until the next day saying she didn't know if I gave the med or not.

It was two days ago, and this is all I can think about.

It's nightmarish making mistakes. I can't stand it. The guilt is overwhelming and I don't know how to feel better about it. I wish I knew what happened. I don;t know if she found it in the pt's med drawer. I have tried calling her today to no avail.

Do people get fired for this? Do you think I will be let go? I go back on Saturday and I am really worried.

[happystudent, RN]

Bummer....We all make mistakes...Try not to beat yourself up. I too made my first med error my third day on the floor!

I gave a pt an extra asprin. What happened was, I remember going thru the MAR and double checking with the pyxis on this pt meds. Well I didnt realize that he was given the asa in the A.M. because it was signed off in the wrong box. When my preceptor and I went over the chart we both realized what happened. I was mortified! I couldn't believe it! My first Med error!!!!

We notified the NP and she was SOOO supportive of me. I felt like a heel! She said that the pt will be fine and that she was very impressed that I "owned up" to my error and that I was so concerned about the pt. She went on to say that sometimes people don't admitt their mistakes and that I had done the right thing!

I was so relieved! When talking to other nurses, I was comforted in the fact that they too had made med errors in the past!

So, try not to beat yourself up! You did the right thing. There is no other feeling than knowing you made a med error!

Use this as a learning experience and remember to triple-quadruple check yourself from now on.

And no, I don't think you will be fired!

If you always come clean about your errors and try to make things right, you will be ok.

positive thoughts your way :)

[LydiaGreen]

I doubt you will get fired for it. I am a new RN also and made a med error with insulin. Found it myself about twenty minutes later (I gave 5 units too much and it was regular insulin), followed all of the steps that I should have (q15 min checks, notifying supervisor, notifying MD, etc) and wrote MYSELf up. Felt like crap. Still get that tight feeling in my chest when I think about it. I just read the order wrong - it was a sliding scale insulin and I managed to read it backwards. We have our insulins checked by another nurse and co-signed, she read it backwards also. It happens.

As for forgetting to give a med at the end of a shift - it's SO common. Out of five shifts, one of us has to phone at least one nurse once about a med that wasn't signed for - wondering if it was given or not. It's a mistake, it happens.

The point of mistakes is that we learn from them. Any nurse who says they have NEVER had a med error is unfortunate in that their error was never caught for them to learn from it and learn how not to make that error again.

Don't worry - you'll be okay. It will likely come up in your performance review at the end of orientation, admit the mistake, own the responsibility for it, and explain how you will avoid errors in the future.

[meownsmile, BSN, RN]

Relax a little bit. Number one, your preceptor should be checking MAR entries and going over meds with you this early in your orientation. Im not going to say you dont need to slow down a bit, keep your mind on your work and dont let yourself get distracted. That will be your input into how to protect from further errors.

I doubt that this will be enough to fire you, but they may ask for a meeting and expect you to be ready to give concrete solutions to how this can be avoided again. I just gave you 3. If things keep happening they may ask you get some re-education on medication administration, which may come from their education department. Whoever did the initial part of the orientaton (classroom) stuff will be prepared to help with any refreshing you might need. Dont let it get to you if they suggest it. Be receptive and make sure you initiate contact with whoever you need to for follow up. They are looking to see that you are taking action in your own behalf. You'll be ok.

[happystudent, RN]

YOu got some veeeeery good advice here, geekgolightly!!!!

:)

[Tweety, BSN, RN]

If they fired everyone who made mistakes as you desribed then we'd all be out of a job. Relax.

Making errors should be a learning experience not a punishing one. Please stop punishing yourself. Learn from it. Decide how to change your processes so as not to repeat these or make similar errors and move on.

You're human, you're an excellent nurse, you can't rewrite the past. It's over.

Best wishes.

[geekgolightly, BSN, RN]

I really appreicate this advice. I felt so low when I reported it to my preceptor and to the physician about the insulin... and then to make the second med error (not giving it is an error) that day has flipped my wig. I feel embarassed. Ashamed. Like I won;t live it down; that the nurses involved will never respect me. Or that it will take a while. I just have to swallow my pride and try to focus on doing my best. We have an insulin sheet where the PCT writes the blood sugar and we can write on that page how many units we are giving, and I will never again give insulin without checking off on that sheet FIRST before I go to the PYXIS and then right before I give it I will check that sheet again as well as the MAR.

With the second error, it was about my failing to communicate. If I said I would give that medication and then decided to put it in the med drawer I need to communicate that to both my preceptor and to the next shift nurse. Once I take it out of the PYXIS it is hard for anyone after me to know what I have done. I really hope the night nurse calls me tomorrow.

Thank you all for your support, empathy and advice. I need it.

[geekgolightly, BSN, RN]

You're human, you're an excellent nurse, you can't rewrite the past. It's over.

this should be my mantra. gracias.

[lady_dolphin]

I think we all have made med errors. I know I have. I try my best to learn from it. One time I had to give 3 units of humolog and it was in the patients box with her name on it. I got it out and drew it up and gave it to her. About 30 minutes later I noticed it was regular insulin in the box. So now I don't go by what the box says anymore. I felt terrible. And it was the first med error I made and I notified the doctor. He asked me what the H..ll do you want me to do about it. That made me feel worse. I continued to monitor her blood sugar all night long after that. So now I slow down and double check everything. Don't beat yourself up or it. Try to learn from it and slow down. We are human. We learn from our mistakes.

[Tweety, BSN, RN]

this should be my mantra. gracias.

You're welcome. I'm sure by the time you get back to work, everyone else will have moved on and their respect for you will remain intact. In fact they may respect you more for being honest about it.

[TaoRN]

Thank you for sharing this with us. You are going to be a great nurse because:

1) You are owing up to your mistakes

2) You care about the quality of your work

3) You are reflecting (I know, right now it feels more like anguishing!) about your nursing practice, especially how you are going to prevent future errors.

Take advantage of all the great advice offered to you. This is a tough learning experience, but you have the "right stuff" to get through it!

[sheilagh]

We've all been there, and I myself was convinced the whole floor would be talking about it....well when I came back to work it had been basically forgotten except for some gentle ribbing from some co-workers.

Iwent into a shared room ready to start my first IV, and I was nervous but had all my supplies and didn't want the gentleman to know I was knew so I confidently explained my procedure and went ahead and did a textbook IV insertion !!!! I was beaming, I was the IV queen !!! (Turning very red faced and starting to sweat ) the patient in the next bed says to me as I'm leaving the room " I'm getting an IV soon also, could you do mine too, you seem good and I'm nervous", little did he know that I at that moment realized the IV should have been started on him and not his pleasantly confused roomate who said yes to every question I asked ( like his name ).(check your ID bands ) Everyone ribbed me that it was a shame it wasn't a manual disempaction!

They forgot the moment someone else made their own mistake.Luckily no one was hurt, but it could have been worse, but that is how we learn.