Made a bad mistake

JKL33 · Feb 18

When I was a newer nurse, my patient had orders for both oxycontin and immediate release oxycontin. She was in terrible pain. I spent a good portion of my night trying to provide additional relief with doses of oxy IR whenever she was allowed to have another....except that it wasn't oxy IR, it was long acting oxycontin I was pulling from the pyxis. I realized this when I went to Pyxis yet again around 0630 and was pulling out more medication. Now there were some situational facts involving the way the names of the meds were displayed on the screen that made it an easier mistake to make, but it was it was still a failure to fully read the extended/hidden part of the screen and to understand the naming difference and stuff like that. A failure of 5Rs on my part.

I felt exactly like you. That happened...a long time ago...and I remember calling the patient's physicians, confessing and apologizing to the patient (who was beyond kind and forgiving), writing an incident report and telling my manager. Tiny details forgotten but most of it has stuck with me for many years now--in a good way. It helped shape who I am as a nurse. I would imagine that most caring nurses who take their job seriously feel like you do when a mistake is made, and most/all of us have made an error.

While we aim and take steps to try to prevent something like this, to expect that we personally should not and MUST NEVER make a mistake or else something is fundamentally and personally wrong with us--is expecting perfection. Instead what is needed is to keep up all safety efforts as best we know, and when life/circumstances/something goes wrong, we take immediate steps to keep the patient safe and to rectify the situation as best we can, getting help immediately if needed. We then contemplate what went wrong and absorb it and understand how to do better....and then move forward.

Everything is okay.

Davey Do · Feb 18

I empathize with your situation, Tierno. In my 40 years of nursing, I had quite a long list of med errors, but no one cried (well, maybe except me), no one died, or had to be sent to ER.

"To err is human, and to forgive (even yourself) is Devine."

Sometimes a decade would pass between my med errors. Each time, I said, "Well, I learn from that one", only to live and make the same stupid mistake later. It's all water under the bridge now and will be for you someday.

Bottom line, Tierno, you named it, claimed it and was proactive. For that, you have my respect.

delrionurse · Feb 19

I can see the technical error, but it really is no big deal. You gave her half the dose because she said 15mg was too much. You were taking care of the patient. From an admin standpoint, it's a narcotic so maybe it has to be accounted for. I actually made this same mistake except it was with Lyrica 100mg and that is a capsule! And the nurse I wasted with didn't say anything, she just verified☺️. Another nurse is the one that said something. See how ridiculous I felt giving 50mg of a 100mg capsule (you can't! ), you have to eyeball it. 100mg was the dose dispensed by the Pyxis. I was embarrassed as I should have known this, I made a mistake and I owned up to it.

heron, ASN, RN · Feb 19

If the ms contin was ordered for pain from the previous day's accident, OP was kinda set up. That order was inappropriate to begin with and should have been questioned.

Was the patient also being treated for chronic pain prior to the accident? MS Contin isn't usually ordered until the 24 hr dosage requirement is established with immediate release morphine. The OPs instinct was correct - to titrate the dose when side effects occured. The mistake was not speaking to the ordering practitioner first and cutting the pill.

I agree with previous posters that OP handled her mistake honestly and with integrity. Good job!

Tierno · Feb 19

I sincerely appreciate all of your responses. I felt like I was all alone but with a huge spot light on me for the whole world to see and the deep voice of one of those guys in a movie preview saying "This one should not be a nurse!" Now the spotlight is off, the deep voice disappeared and I'm part of the crowd. Thanks again.

Davey Do · Feb 19

Tierno said:

I sincerely appreciate all of your responses. I felt like I was all alone but with a huge spot light on me for the whole world to see and the deep voice of one of those guys in a movie preview saying "This one should not be a nurse!" Now the spotlight is off, the deep voice disappeared and I'm part of the crowd. Thanks again.

I love it when that deep voice disappears, and we are allowed to examine the situation from more of an empathetic, logical perspective!

Lpn to RN · Feb 27

I made a med error as a nursing student. I was already an LPN and was in school for my RN. The day was already hectic and we had to wait for this med from pharmacy for a couple of hours. I made 2 main mistakes and my instructor made one. Firstly, I didn't scan the medication before giving it. I scanned the packaging after administration. (I had already worked in the hospital and I had never given meds without scanning the packaging first). Secondly, I didn't read the order correctly and carefully. The order was for Oxybutynin 5mg every morning and afternoon (10mg per day). I administered the WHOLE pill at once. My instructor did not catch my mistake and he was not even looking at the computer. Fortunately Oxybuynin doesn't have many side effects, and the patient was all right.
I was so embarrassed and scared. But I did tell the primary nurse for my patient.

The most important thing is that you took responsibility for your mistake and didn't try to hid it.