Live and learn...my med error!

[Antikigirl, ASN, RN]

I have been a nurse for 7 years and only one med error done within my first week of being a nurse. Well after two days ago..that has changed, and let me tell you...it hurts! However, since I am a believer in sharing stories like this to help others not make the same mistake...let me share this with you so you don't do what I did!

It was a crazy night, I was floated to a floor and wound up with 6 pts. Two were total admits from MD offices (TONs of paperwork and stablization), two discharges, one using translator phone (long d/c), then one fresh post op that had out of control pain and nausea/vomiting, and one old lady who loved being pampered and was on the call light every 5 minutes or so. Needless to say I was going nuts...no CNA, no help!

Then...after 4 hours I was floated to another floor....yeah right after I got it all done in a rush and everyone was sleeping..grrrrrr! I went to the next floor and got 6 whole new pts! No breaks, tired, and not happy about this! Three post ops, one gal who was suffering an infection and was pregnant, and another very quiet pt. All was crazy with med passes~! Heck, even through three folks were on PCA's I still had back up pain meds every 1-2 hours, and they were all using them! It was a nightmare and wound up finishing my 2000 meds at 2300!!!!!!! I needed help, but couldn't even tell anyone where I needed it because I was so flustered...not like me at all!!!!!!!

So towards end of shift, I wound up giving some Dilaudid in one gals PCA...and stupidly I also gave another Dilaudid into anothers PCA who was supose to get morphine! Okay...for those that don't know...Morphine is regulated in mg, Dilaudid in POINT something mgs! Big difference! I left and didn't even realize I did it!

It was caught early thank goodness, oh and yes...it was the pregnant girl I did it too. When I found out I was instantly in tears asking about the gal and baby. They were fine but very angry...which I would be too. I expected to be fired...but was not.

Since this was a workload and management issue in scheduling as well as my error...I was not fired, but will help them come up with ways to avoid this from happening again! I will work on a plan, including how loud those PCA machines are when they are empty (frazzles an already frazzled mind, and upsets pts!), and how to clearly mark the different syringes (although I totally just goofed...I thought it was Dilaudid so even a difference in syringes wouldn't have helped....uhggggg!).

I think about the damage done, not physically to the Pt..but emotionally! My managers said "she is fine" and I said "nope, damage to her emotions, trust, and perhaps spirit was done because of my stupidity...that is a longer lasting thing to bear for pts and myself".

Please, if your loads are too much...stop, and tell your charge nurse and seek out help! If I had just taken the time to talk to my charge nurse and explain things...all could have been avoided by me rushing around doing things half way or not at all. That is NOT ME at all!

And here's hoping I still have another 7 years before my next mistake...LOL!

[LoriAlabamaRN]

Oh hon, noone could be expected to handle a situation like that without SOMETHING giving! That hospital should be ashamed of the working conditions. If I were you, I would look for something better! I know now from experience, something better IS out there!

Much love!!!

Lori

[Elisheva]

I think you're a terrific nurse for sharing your story. Errors happen; thank God no one was hurt. The most difficult part for the nurse is forgiving him/herself and moving on with confidence. I hope you can do that.

[Antikigirl, ASN, RN]

Thanks very much! My hospital is actually very very wonderful and we were all shocked this happened, that is why I didn't get 100% of the blame!

Also, and I thank my lucky stars...when it was found out...two doctors, all the nurses on my floor that were there, all the administrative nurses all sided with ME! They said I was one of the best, and this was beyond out of character! And added, if it wasn't me...it could have been worse! My team stuck up for me! That made me so happy!!!!!!!!!! They could have turned their backs...but they all stood up and made sure under no circumstances that it was a scheduling error that caused this, and would have for anyone!!!!!!!!

Too cool, that helps a lot! I love the staff I work for...we stick up for one another..including the MDS!

[Jules A, MSN]

Thanks very much! My hospital is actually very very wonderful and we were all shocked this happened, that is why I didn't get 100% of the blame!

Also, and I thank my lucky stars...when it was found out...two doctors, all the nurses on my floor that were there, all the administrative nurses all sided with ME! They said I was one of the best, and this was beyond out of character! And added, if it wasn't me...it could have been worse! My team stuck up for me! That made me so happy!!!!!!!!!! They could have turned their backs...but they all stood up and made sure under no circumstances that it was a scheduling error that caused this, and would have for anyone!!!!!!!!

Too cool, that helps a lot! I love the staff I work for...we stick up for one another..including the MDS!

This is a very nice testament to their trust in you! Thank you so much for sharing this story as I'm sure many of us also try to be SuperNurse instead of insisting on back up when needed. Just reading about your night makes me frazzled. Hugs and again thank you for sharing. Jules

[rnsrgr8t]

I am so sorry this happened to you! I am glad your hospital is standing by you! Something to consider, when I was a floor nurse, when changing the PCA vials, 2 nurses had to do it and cosign it to help eliminate the error that happened to you. I don't know if that is feasible or not where you work but it is something to consider. Good Luck and best wishes!

[rn/writer, RN]

Hospital equipment comes with messages that its limitations should not be exceeded. Maybe hospital personnel should be labeled with a similar caution.

Your double assignment was a mistake (or ten) waiting to happen. Too much to keep track of, too much to do, too much to anticipate. You already had a heavy load. Then you were blind-sided with a whole new assignment when you were pretty well used up. Adrenalin carries you only so far.

I reiterate--if you were a piece of machinery, they'd know not to overload you or you might blow a fuse.

I'm soooo glad the patient and her unborn child are okay. And I'm happy the rest of the staff is standing by you and that the hospital is using this as a learning opportunity for everyone. They truly owe you an apology for putting you in such an untenable position, but at least they aren't turning you into a scapegoat.

Thanks for having the courage and the consideration to share this with the rest of us.

Learn what you can from this and then LET IT GO.

[cardsRN]

first- triage- we've all made errors. the nature of our job is such that when we do, someone could get hurt. that's unfortunate because we're all still human. thank you for sharing your story. an error should be turned into a learning experience for all.

the second thing i want to say will not make me popular, but i feel that in the interest of fairness and support for learning and those who are new to our profession, it must be said. some of the posters here offering such wonderful support to an experienced nurse who made an error are the same people who were absolutely shredding a new grad yesterday for an error she made (concerning a dt sz for those of you who are following). this scenario is not new in the nursing world. nursing units are just not welcoming places to new people, whether you are a new grad in our world or an experienced nurse transferring to a new environment (as i have recently learned). i only wish that we could evaluate all situations with an open mind and not be so quick to judge harshly.

[Antikigirl, ASN, RN]

You guys are just awesome, thank you so very much!

I have learned so much from others who share their errors, and I felt mine was a good one to learn from...since it does happen more often than it should. I was even thinking of putting it into the new grad/student RN area to show that even a nurse of 7 years can make a mistake and to learn from this one! Because of the openess of others who have told of their mistakes, I think I have learned so very much! Now...it is my turn to return the favor!

I told my supervisor I will be having someone double check me for a while, can't hurt! And others have said they wish to do the same! So cool! I guess I am so not alone with this type of error, and we all want to cut down on any type of errors!

Thank you so much for your support, and continue to share this story to others so they can learn from it too. My heart really honestly came out my throat when I found out it was that particular patient and I was so worried about her and her baby! Thankfully...the med I accidentally gave was actually a safer med for her, but too high of a dose via the PCA. I was relieved, but considered the emotional aftermath (for the PT!) and want to remind folks that that is a big part of the territory too!

Huggles to all of you!

[buddiage]

thanks for sharing... wow.

Had the same thing happen in clinicals (someone else- an employee) gave so much Dilaudid (doctor's mess ended up that pharmacy didn't do it right and nurse didn't check). Woops! Pt went downhill, hardly breathing and his bp was looooooow, they did catch it on a routine check on his room, thank god, but the nurse who gave it got a new orifice and we were all told to stay out of her way.

[GeminiTwinRN, BSN]

I am so glad that in the end your patient (and unborn baby) were ok. I also appreciate your sharing your story with us. It is so unfortunate that you were under such stress - I can't imagine what your night was like! It sounds absolutely horrid!

I do have 2 questions though.. you mention that "if it wasn't me, it could've been worse..." I'm just wondering what you (or your co-workers) meant by that. The error was the error, no matter who made it. How could a different person making the same error turn out to be a worse outcome? Or did they mean that a possibly DIFFERENT, worse, error could have been made if it were a different nurse? I guess I'm confused by that.

The other question is why are you saying that you actually gave the patient a safer med for her? Her physician is the one who makes that call- I'm confused about whether or not that physician is the one who told you that you had given her a safer med, or are you just extrapolating?

Where I work, all the PCA syringes are double checked by another RN, but that doesn't mean a mistake couldn't happen. As we've all seen, just because someone "signs" behind you doesn't mean that they've actually put their eyes and hands on the med you are giving and that they are verifying.

You seem to be a very competent nurse, I'm surprised that you've decided to have someone double check you for a while. Hopefully the conditions you described won't be happening again, or anything even close to that. I'm sure you will be triple checking your own self.

Please don't take offense at my questions, I don't mean to offend. I'm just curious as to the meaning of your post in those areas.

[Kim O'Therapy, BSN, RN]

Thanks for sharing your story. I start my first clinical rotation next week and your story will reinforce what they keep telling us in skills lab about triple checking everything. Lesson learned here too.