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.
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.
This is great advice from Tweety. I once gave somoeone 250mg of chlorpromazine which they were not entitled too! I was mortified but thankfully the recipient was a Psych patient with a tolerance for drugs. When investigating how it occurred it turned out to be a "systems error". Unfortunately for me (and the client) I was the first one to make a mistake this way. I changed the sytems of medication sheets and administration so that noone else could make the dame mistake in the same way. I still felt sick though when it happened! Don't beat yourself up about it!
Meds should not be scheduled for shift change times! Sometimes am meds need to be taken at mealtime (usually 7am) so we schedule them for 6:30. Night shift gives and charts the med. If your facility has computerized med charting, nurses (or the shift supervisor) should be encouraged to print out a copy of uncharted meds as a reminder for staff during the busy am shift change. The system needs to adapt to help reduce med errors, doncha think??
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Lord knows, I have made mistakes. It sounds to me as if you are VERY conscientious and caring. Chalk this up to experience and a reminder to recite the 5 "rights" when administering any med. Get back on the saddle and ride, it will be ok. You are way too caring not to do a good job. HUGS!
We all make errors. I've had a few in the ICU, and when I was a couple months out of school I made two in one day too!!! It made me feel terrible and wonder if I could get my act together enough to be a nurse.
The first one I gave Demerol to a LOL with gallstones. Problem was she'd just come back from her chole and had all new orders - for morphine. The doc wasn't too upset with me. Actually, as I recall I had him write me retroactive order to cover my butt - nice resident that day.
Second time a few hours later, I read an old order that had already been done and gave a young woman an extra liter of NS, wide open. She wasn't harmed either, except she had to pee a lot that night. When I called the doc, he said "I'm glad she's well hydrated."
You will make more in the future, but probably not two in a day again. It gets easier and doesn't take as much concentration after a while.
Don't punish yourself anymore, it was a lesson well learned and we have all been there at least once. My med error was my first week as a nurse, mind you I was a hairdresser before this so the nursing world was a whole different ballgame. My first week as a nurse they schedualed me fo 4 days in a row of 12 hour shifts of orientation. I did not know that this was a bad thing. So on my fourth day in a row, very sleep deprived due to the long commute to this wonderful hospital, I was with a nurse that was drilling the heck out of me on my meds, and I was shook up trying not to show it. She sent me to draw up one of our pts. insulin and when I brought it back for her to check & sign off on(per hosp. policy,thank God) she yells(it's supposed to be 4 units of insulin, not 40!!!!!!) I ran to the bathroom for about 10 min. and then was paged to our nurse manager's office ready for another drilling. When I got in there they asked was this my fourth day in a row and said it was thier fault for putting all that on a new nurse, and actually sent me to the break room for an hour break, and gave me very easy assignments the rest of that day. I was fine when I came back 3 days later(after some much needed sleep). And everyone was wonderful and very helpful. Best of luck to you, they won't fire you.:) P.S. I never gave the pt. the insulin, I was too busy running to the b-room. My preceptor corrected the dose and gave to pt.
you are new, and in orientation. It is alot of information to absorb very quickly. Even after being a nurse for many years being in a new enviroment can be overwhelming. The fact that you take responsibility for your error shows that you are a good nurse. Do not be so hard on yourself.
orientation by the DON in Two Hills many years ago. We just did the stuff we needed to do to fix it.
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.
This is very scarey stuff indeed but it happens and we just hope and pray the consequences are not dire. The mistake that sticks in my mind happened on a busy med/surg floor when I had 4 years under my belt. I was giving Heperin IV - I don't remember all the details but I had to work it out per the patient's weight. When I had worked out the dosage I thought "wow that is a lot!!" so I checked my math again and I got the same dose. So then I asked another nurse to check my sums and he agreed with my dosage too. We then checked the drug book to see if such a large amount of Heparin was sometimes given and it was in there - although it was at the highest point of the range given. So I went ahead and gave the patient the Heparin. The patient was in because of blood clots and was scheduled for a Greenfield filter. I can't remember when or how I came to the realisation of what I had done ...... but oh my God was I scared to death when I did realise .... I had done all my sums using the patients weight in pounds when it should have been kilograms!! *ARGHHHHHH PANIC* I had to call everyone, supervisor for the hospital and then the surgeon. It was nights too so you can imagine the fear of calling a surgeon to wake him and tell him that. What did he say to this very scared RN ? - he said " well I guess we don't need to worry about him throwing any clots tonight do we ..... keep an eye on him and call me in the morning" The patient did fine. PHew! That's not the only one but it sure is my scariest.
There are two kinds of nurses, those who made med errors and those who will make med errors. Don't be too hard on yourself, chalk it up, learn from it and move on.
Really, honestly, there would be no nurses if everyone was always fired for medication errors. Just make sure you let the proper peple know when you have made one. Med errors become unsafe when people are not aware of them. For that reason I would be more scared of a nurse who has "never made a medication error".
I had a good friend who was a level 4 nurse, preceptor, charge nurse, the whole works in a large teaching hospital in a CCU. At 0600, per protocol, she changed the bag of fentanyl hanging on a vented patient, and hung her AM antibiotic, Ancef, I think. When giving report, the next shift nurse checked the pump with the fentanyl to get a count, since it was a controlled drug. Imagine her surprise, when the ancef was hanging on the pump, and the fentanyl had been completely infused while hanging gravity flow. My friend had inadvertanently switched the two bags that looked alike....both 100 cc NS with additives. Fortunately, the patient was vented and did not suffer any ill effects, but my friend was devastated, as you can imagine. After this, the pharmacy started labeling drugs that needed to be on pumps with a bright orange sticker. Yes, she should have read the label again just before hanging, and after spiking the bag, but how many times are you interrupted during seemingly routine tasks? Stuff happens, and we just pray that no one suffers any harm. We are in a job where we do have peoples lives in our hands, and the responsibility is overwhelming at times. We just have to move on, doing the best we can, and let go.
When I called the doc, he said "I'm glad she's well hydrated."
Farkinott, RN
581 Posts
This is great advice from Tweety. I once gave somoeone 250mg of chlorpromazine which they were not entitled too! I was mortified but thankfully the recipient was a Psych patient with a tolerance for drugs. When investigating how it occurred it turned out to be a "systems error". Unfortunately for me (and the client) I was the first one to make a mistake this way. I changed the sytems of medication sheets and administration so that noone else could make the dame mistake in the same way. I still felt sick though when it happened! Don't beat yourself up about it!