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Discussion

Is this nitpicking or does the instructor dislike her?...

Ok, today on clinical my partner drew up some ativan. It was 2mg/1mL. Dose is 0.5mg .She drew up all 1mL into a 1mL syringe. She thought it was 0.5mL , temporary lapse in judgement. Shows the syringe to the instructor and Primary Nurse ( whos in the med room with her watching her draw it up ) alerts her of the correct dose. She fixes it and wastes the ativan up to 0.25mL which is the correct dosage.

we cant do IV pushes alone, so the primary was with her when administering the ativan.

We go to lunch, she gets back and our instructor pulls her to the side and explains that she incorrectly calculated the dosage, and she is getting an unsatisfactory for the clinical day (even though she rocked it out passing a crazy amount of meds to 5 patients today), and explained that shes gonna do med passes with her for the next 4 weeks.

heres how i see it. shes a student. shes learning, she mixed up her dosage/ concentration the instructor let her know, and it was a LEARNING experience. She did not admin the incorrect dose to the patient and the patient was not harmed in any way.

I dont see why she needs to do this to her. at this level of the game its a bit degrading. and i feel like shes being picked on rather than coached.

Am i being naive in the way im viewing this ...maybe someone else or another nurse can provide some insight for me?

She was feeling really upset and frustrated and sad about it and i just told her to suck it up bc we're almost done ...ya know =/

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    • Admin

    I work in the OR, and we routinely give Versed IV. I've seen people go from awake and talking to asleep and unable to maintain their own airway before we even finish pushing half the dose in. Just because it was caught this time doesn't mean this is her only medication error. Also, Ativan has a sedating effect. Giving too much can cause respiratory issues, and giving it IV means it works much faster. So no, I don't think this is nitpicking. It's a potential serious issue that could have had dire outcomes for the patient. 0.5mg may not seem like much, but if the patient is narcotic naive, that little bit can be enough to cause major problems. There won't necessarily be anyone checking her meds once she's a nurse, but this is the kind of thing she should learn from. The instructor wouldn't be doing his/her job if they weren't double checking this student's meds. Heck, until we were in practicum (and sometimes even then), we had to have our meds double checked by either the primary or the instructor (who had to sign us off before we were allowed to check with only the primary).

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    Call me harsh I suppose but I think it's a big problem. If the student is at the point of being able to give IV medications, this type of error is worrying. If the medication is 2mg/ml and the dose is 0.5 mg, there should be no difficulty working out the amount to give. It's a very very easy calculation.

    If I was the student, I would fully expect to be supervised very closely for a period of time after making an error like this. No, the patient wasn't harmed because it didn't get that far (so it's not a medication error from the patient's point of view) but from what you wrote the student didn't realise there was a mistake until it was pointed out to her.

    Others may disagree.

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    The instructor may be thinking that she is incompetent and a liability. Especially since they drill you in lab and theory a billion times before they allow you near the real thing in clinicals. A sobering reminder is that there are over 90,000 medication errors per year in the us. So this is a big deal, whether student or licensed nurse. Because the pt is a real person.

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    • Experts

    No not harsh at all. She was potentially going to give double the ordered dose.There was no harm this time but if she doesn't catch the difference between 0.5 mg and 0.5 ml she could be headed for a big error down the road.

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    • Author

    to clarify it wasnt me... LOL, im not trying to "pretend" its my partner. lol

    Completeunknown- i completely agree with you, about her not realizing the mistake until it was pointed out. But i cant tell you how many times my instructors or primary RN's have flubbed sometimes. & they dont have anyone checking them. , & its sometimes we the students pointing the error out.

    i mean we are all human, and make mistakes, and i think she was just a bit hard on her about it.

    I appreciate the insight i have recieved so far. It helps me look at it from a different point of view since im so close to the situation.

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    since the error wasn't the op's error, the op isn't in a position to know whether this is an isolated event or as part of a pattern. if it's part of a pattern, the instructor is being diligent -- appropriately so. but it is a mistake, a big mistake, and part of the instructor's actions may be based on the reaction received when the mistake was pointed out.

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    • Experts

    It's not nitpicking, and it's not "the instructor must not like her." It was a med error, plain and simple.

    Her error has the potential to be VERY serious. It's not "just" Ativan. IV benzos will knock a patient on their rear; a double-dose may knock the wrong patient into respiratory depression. Or imagine her giving double the dose of a vasopressor or a antidysrhythmic (sp). All because she didn't know how to do the math.

    It also was caught in time, but what about when your partner is on her own and there's no one to double-check the math (whether no one's there or she thinks she's done it right and doesn't seek anyone out to check it)?

    If anything, hopefully this experience and the next four weeks of med passing will make your partner more vigilant about medication administration and dosage calculation. No one was harmed...this time: she was lucky that it was caught, even if it wasn't her that caught it.

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    to clarify it wasnt me... LOL, im not trying to "pretend" its my partner. lol

    Completeunknown- i completely agree with you, about her not realizing the mistake until it was pointed out. But i cant tell you how many times my instructors or primary RN's have flubbed sometimes. & they dont have anyone checking them. , & its sometimes we the students pointing the error out.

    i mean we are all human, and make mistakes, and i think she was just a bit hard on her about it.

    I appreciate the insight i have recieved so far. It helps me look at it from a different point of view since im so close to the situation.

    Yes we all make mistakes but that doesn't make this mistake (or any mistake) okay and something that doesn't have to be addressed. I've been a nurse for a long time and I still make mistakes and when I do I still get 'told off' and have to show that I've thought about what happened and that I've learned from it, or have to have my work double checked for a time, or something. There are always consequences, sometimes you won't see them, sometimes they come from within rather than being imposed by someone else, but they're always there.

    If I catch myself about to make a medication error, I don't think 'oh well, it's okay because I didn't actually do it and the patient wasn't harmed', I think 'oh my god, that was very close, the patient could have been harmed or killed by that, now what do I need to learn or to change about the way I do things so that never happens again?' If someone else points out that I'm about to make a mistake, the same thoughts go through my head, I don't think 'oh well, it's okay, no-one is perfect and so-and-so made a mistake last week'.

    Good luck to you and your friend! :)

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    I agree that it isn't nitpicking. This is a serious mistake. There are certain meds than can have a very negative effect on the patient, and this is one of them. If the nurse did not catch it, then the student would have given this and possibly killed her patient. Yes the instructor needs to follow her and ensure that something like this does NOT happen again and ensure the student knows how to calcuate meds. Personally, Im not sure how she went from 2mg/ml being .5ml for her dosage....perhaps she needs some dosage calc review?

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    I recall being chastised one day for not checking patient identifiers. I knew who he was, and yeah yeah. Anyway, we can't give any kind of meds without faculty present so I walk in with about a dozen pills and a syringe of insulin. I'm talking to the guy about where he had his insulin given last time, and the instructor starts opening the pills, dumps them in a cup, hands the guy his water, and tells him to swallow. What was funny is that she never checked patient identifiers either. I was quick to point that out to her when she wrote me up and refused to sign the document until she wrote her own which I signed as a witness, lol. I probably won't pass now. They hate me, but I don't give a crap anymore.

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    Another possibility is that staff are "supposed" to report near misses. Perhaps the primary nurse did report the near miss and informed the clinical instructor as well.

    Yes we are all human and make mistakes, but sometimes those mistakes kill people. Just to put it into perspective I have seen whole bags of dopamine, levophed, and heparin infused into a patient in minutes with horrific outcomes. My pharmacology professor also puts it into perspective..."The only difference between a drug and a poison is the dose".

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    In nursing school, we had to have our clinical instructor with us for every med pass (and we were not permitted to to IV push medicines). In addition, I'm not sure how severe of a punishment it is to be given an 'unsatisfactory' rating for any one clinical day, so it's kinda tough to say if the punishment is appropriate or not.

    In my opinion, this is not nitpicking on the instructors part. I realize that this may have been a 'lapse in judgement,' but my guess is that a large percentage of med errors result from such a lapse on the nurse's part. In my mind, the learning experience is to pull the student aside, like the instructor did, and make her realize that without the second check, she could have made a serious mistake. While unit dose meds are nice a lot of times the nurse has to give half, a quarter, or some other percentage of that packaged dose and it is the nurses responsibility to know how much he/she has to give.

    It sounds to me that the instructor handled the situation appropriately given the potential seriousness of the situation.

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