Just realized a med error.. What to do?

Nurses Medications

Published

Hello everyone! Looking for advice on a med error I just realized I made 2 days ago. I randomly start thinking about work and just realized I made a mistake. To make a long story short, there was a situation where I needed to give IV ativan. Not realizing, I gave it without diluting it. I gave it through a peripheral IV and y-sited it with NS running which should have diluted it some. It was a very small amount (.25 mL) but I feel awful and just stupid that I didn't look at the administration instructions better. I am a new nurse and pride myself on how carefully I look at medication instructions. The patient is definitely fine because I had them the whole shift and had them yesterday as well. I was researching the medication and found that the reason it should be diluted is because of how viscous it is - but it did not seem viscous at all when I was administering, probably because it was such a small amount. Any advice on what steps to do here? I don't want to make it seem like I am covering it up because I just noticed now. 

If I understand your post correctly you pushed it through running saline which is how plenty of nurses give lorazepam. It is diluted by the time it reaches the patient.

Just lock this in your memory and move forward. ??

Specializes in ER.

The reason you dilute it is mainly for practical reasons, not really safety. The patient might have gotten a little less of an already very small dose. That's because some adhered to the syringe most likely. Definitely not worth the hassle of filing a med error report. 

+ Add a Comment