IV Med Error

[EDNurse23]

Looking for advice - I have been a nurse for 3 years and last night made my first ever medication error. I gave Bentyl IV instead of IM as ordered. I have never given this med before, I have seen it written as a prescription but it is not a common med used in the ED I work in. The patient had 3 other IV medications ordered annd I assumed that Bentyl was IV push as well. (I should have double checked the order, I know). After administering it, I panicked and was a nervous wreck. I immediately went and told my charge nurse I had made the mistake, then the ED physician. I called the on call pharmacist, who said the biggest risk was phlebitis/thrombosis. I monitored the patient closely for 2 hours and she seemed to be fine with no adverse affects. She was discharged, and her IV site looked fine when I removed it. Still, I am so guilty and was tore up about it the rest of my shift. I cried when I had to tell my charge. Even though the patient seemed fine at discharge, I can't help still feeling guilty and hoping she will be okay with no effects later on. I took all the appropriate streps and even filled out an event report on myself after the fact. Has anyone made a similar error? What should I do? 

[offlabel]

What you're experiencing is an acute physiologic response to your error. As such you really have no objective perspective on the reality of the situation. This time next week, this will be no big deal to you other than an uncomfortable learning experience that you'll rarely ever call to mind again with any emotion at all. 

[JBMmom, MSN, NP]

You should take a deep breath, realize that no harm has come to the patient, and move on. Clearly it's not a mistake you will ever make again. And you've now joined one of the biggest groups in nursing- those of us that have made a mistake. I was fortunate with the med errors I have made that none were serious and I learned from all of them. give yourself some grace, it's all fine. You took responsibility and you'll learn from it. Good enough.

[HtownNP]

As nurses, we've all made mistakes in our career. It's a natural part of being human. It sounds like you followed all the right protocols by informing your charge nurse, doctor, and pharmacist. I'm sure you or the charged filled out an incident report. Don't beat yourself over it. You learned mistake and will be extra careful next time. 

[DavidFR, BSN, MSN, RN]

Errror is human and we all make mistakes occasionally.

The important thing here is your reaction to what happened. You did EVERYTHING right and in the best interests of the patient. Be proud of yourself.

[delrionurse]

Don't worry. ED's deal with high risk, high priority drugs at a fast pace. Don't beat yourself up. 9/10 people have probably made the same mistake. You will learn from this. Double check and don't let anyone rush you. 

[JKL33]

It'll be okay. Just review your thoughts/actions and learn the lessons associated with this. I commend you for actions taken once you recognized the error.

 

Quote

9/10 people have probably made the same mistake.

I indeed have made a very similar mistake, but it was not with a med I knew nothing about and didn't look up; it was with a med that was commonly given in my area, and almost always given by a route other than the one that was ordered. And I gave by the "usual" route instead of the ordered route. And it turned out that the provider meant to order it by the route I used.

I don't mean to be "that person" and I do not excuse the mistake I made, but I do think that not looking up a med one knows nothing about is an additional (and possibly more worrisome) issue that requires reflection if that is what happened here.

 

[Nursingjourneyguide]

Making an error as a nurse can throw your confidence out of the window. But remember you are human and can make a mistake. The importance thing is to learn from the mistake and move on.

[Jurse, LPN]

Sorry to hear that. Hugs. It happened to me too.





The pt kept asking me questions while I dispensed medications. I was lucky that the error wasn't serious.  After this med error, when people ask questions,  I politely ask them to ask me after I'm done giving them their medications. I do not want people to bug me during med pass unless it's urgent or an emergency. Everything else can wait.