Live and learn...my med error!

[Antikigirl]

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!

[A Miracle]

ruby,

i have been doing some research on pca's and how easily errors can happen.

would you mind me asking you some questions directly by email?

you seem to know what you are talking about, and i hope you can help me understand a few things.

thank you,

kimberly :wink2:

thanks for sharing. it just goes to show that anyone can make a mistake -- and one of the lessons to take away is that making a mistake is understandable; covering one up is not. i've seen more than one nurse make a mistake, lie about it, and even enlist others to help cover it up. kudoes to you for being open and honest!

our institution requires a double check and cosign of pain orders and pca programming with another rn each time we change the programming or the syringe. it's painfully difficult sometimes to find another nurse, but might have prevented this error.

anyone who says they have never made a med error is either lying or just doesn't know they made it . . . maybe we should start a thread on med errors. it might help prevent someone else from making any of the same mistakes!

[iluvivt, BSN, RN]

Why were you forced to float halfway through your shift? This is so unfair to nurses. In California you must accept the assignment and then leave before they consider it abandoment. I used to refuse to do this. I will finish my shift here and then go home I would tell them and magically they would find someone else. Just when you had your original group settled down and had yourself organized they yank you. I was not even there and I am angry. Research your policy or rights in regard to this practice..that is where the problem started!!!!!!!!

[SusanKathleen, RN]

Thank you for writing, it was courageous of you. It will help more than you know - keep that in mind next time you want to beat yourself up.