Looking for your input on ED med error....

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First of all, hello everyone, this is my first post, and i'm new to the site. I'm in the process of orienting to the ED following 2 years of ICU experience (where i started as a new grad). Had a weird situation happen last night, and wondered what other people may think of it.

I was at lunch last night when my preceptor picked up a pt, and when i came back, i immediently began my assessment on a pt coming in, so my preceptor had been taking care of this other pt. As things got busy, he handed me d/c papers for the pt he had cared for and told me to give the pt a motrin on the way out. So i go in the room, say to the pt in the bed-are you miss so and so, she says yes, and i tell her i'm going to d/c her and give her a motrin. Because there are a ton of family members in the room and no where to put things down, i hand her the cup with the motrin in it, and tell her let me see your id band. As i compare it to my d/c papers, i notice it is the same last name, but different first name. I tell the pt her name bracelet is different than my papers, and she says yep, thats my moms name, i tell her not to take the motrin, but she pops it in her mouth, i went as far as to ask her to spit it out, but she swallowed it, saying sorry it tasted bad, i wanted to get rid of it. I immediently tell the dr that the name on her paperwork is her mothers and ask if there was a mistake in the admission, he tells me no, the mother is also a pt, and is also in the room. This is a one bed curtained area, and i would'nt imagine in a million years we would have 2 pts in the same one person room. My preceptor the pt or her mother never stated there was a mother and daughter in the room, and the mother was sitting on the floor with a bunch of other family members, was'nt even in a bed or chair. Turns out, the one who got the motrin was there for abd pain and doc wanted her NPO. I know i made a med error, and have accepted the write up, but i'm mortified that this happened. The patient was not harmed, but the mother complained, and i'm written up, i'm afraid of extending my orientation or putting my job on the line becuase of this. Even the dr was upset that 2 pts had been put in the same room, and no one had told me there were 2 pts, but at that point there was not much he could do except reassure the mom the daughter would be ok (daughter was a minor-16). The daughter was still in testing when i left this am, so if she really did have something wrong (they were thinking appy surgery), i coudl really be in troulbe. What do you guys think? or ever had a similar situation?

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Did you make out an incident report, outlining what you said and did when you realized the name was different, and that the pt took it anyway? It should also have been documented in the girl's notes what happened. If so, you should be fine. Doesn't sound like you did anything wrong to me.

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Specializes in Nephrology, Cardiology, ER, ICU.

Don't worry about it. This is a great learning experience. The ER is chaos by nature and I'm sure you won't repeat this.

If the girl truly has an appy - one sip of water isn't going to delay surgery.

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First of all, hello everyone, this is my first post, and i'm new to the site. I'm in the process of orienting to the ED following 2 years of ICU experience (where i started as a new grad). Had a weird situation happen last night, and wondered what other people may think of it.

I was at lunch last night when my preceptor picked up a pt, and when i came back, i immediently began my assessment on a pt coming in, so my preceptor had been taking care of this other pt. As things got busy, he handed me d/c papers for the pt he had cared for and told me to give the pt a motrin on the way out. So i go in the room, say to the pt in the bed-are you miss so and so, she says yes, and i tell her i'm going to d/c her and give her a motrin. Because there are a ton of family members in the room and no where to put things down, i hand her the cup with the motrin in it, and tell her let me see your id band. As i compare it to my d/c papers, i notice it is the same last name, but different first name. I tell the pt her name bracelet is different than my papers, and she says yep, thats my moms name, i tell her not to take the motrin, but she pops it in her mouth, i went as far as to ask her to spit it out, but she swallowed it, saying sorry it tasted bad, i wanted to get rid of it. I immediently tell the dr that the name on her paperwork is her mothers and ask if there was a mistake in the admission, he tells me no, the mother is also a pt, and is also in the room. This is a one bed curtained area, and i would'nt imagine in a million years we would have 2 pts in the same one person room. My preceptor the pt or her mother never stated there was a mother and daughter in the room, and the mother was sitting on the floor with a bunch of other family members, was'nt even in a bed or chair. Turns out, the one who got the motrin was there for abd pain and doc wanted her NPO. I know i made a med error, and have accepted the write up, but i'm mortified that this happened. The patient was not harmed, but the mother complained, and i'm written up, i'm afraid of extending my orientation or putting my job on the line becuase of this. Even the dr was upset that 2 pts had been put in the same room, and no one had told me there were 2 pts, but at that point there was not much he could do except reassure the mom the daughter would be ok (daughter was a minor-16). The daughter was still in testing when i left this am, so if she really did have something wrong (they were thinking appy surgery), i coudl really be in troulbe. What do you guys think? or ever had a similar situation?

your preceptor set the situation up for a med error, perhaps not intentionally, but the circumstances put it in that direction and the preceptor, being the experienced one, imo, was in the wrong to have you walk in to a room with 2 pts assigned to it.

write an incident report stating the facts... upon further inspection, it was a different first name. apparently both mother AND daughter were placed in this room without notifying me.

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Specializes in Trauma/ED.

Sounds like a good learning experience, just be thankful the med error didn't turn out to be life threatening. When I identify a patient I always ask them what their name is instead of saying, "Are you Mr. Smith?" This method may have prevented a lot of stress and paperwork for you.

BTW, I have had as many as 4 patients in one room (a family in minor MVC).

Also I am curious how your transition is going, we have a nurse from the ICU training now and she is really having a hard time with the pace and "style" of ED nursing. I have heard from others in my dept that it's a lot easier to go from ED to ICU rather than ICU to ED.

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Whenever I give meds I check the id before handing anything over at all ...that's just how I was taught..we check ID band, and ask the patient to state their name & birthdate then we give the med ..we never ever hand a med over then ask the info....I'm sure we could be booted out of our program or at the least put on probation.

Don't beat yourself up..as one previous poster mentioned..at least it was just a motrin & not something really heavy duty...............we all are only human , ya know? But I bet you'll never do that again will you????

That would of been enough to scare me also.........hey just chalk it up as a learning experience and move on......;)

P.S....the mother complained about you BUT she is sitting on the floor in the hospital's er????:uhoh3: ......nice :trout:

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Specializes in Emergency.

You're being way too hard on yourself here. Taking Motrin and a whole cup of water isn't going to stop a needed surgery. Having a spaghetti and meatball dinner ISN'T going to stop a needed surgery.

One hint: never say - Is your name Jane Doe? - probably a third of your patients will say yes, no matter what their name is. And don't have too much faith in those armbands. They're just one more source of potential human error. Have the patient recite to you their first and last names AND allergies EVERY time you give a med, draw blood, etc.

And employers who make reporting a med error a punative experience only encourage staff to NOT report minor errors.

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I agree with all others a valuable lesson learnt we dont blame nurses for errors, due to encouraging cover up, we look at the system instead and find safer ways for everyone to practice,most nurses make a drug error at some point and we never forget how bad it made us feel the most important thing is that we learn from it

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