Made first med error :( Filled out first OAR.

RNcDreams · Dec 13, 2007

Baby steps are important, as a new grad there is a lot of learning to do,as in the 1mg of Dilaudid is about 10X stronger then the 75 mg Demerol ,until you know ,keep checking...Also you undermedicated someone, but sounds like he tol the procedure fine, I've done conscious sedation, one person is out w/ 0.5mg versed, another 7mg..it is titrated to each pt, sounds possible the dose he received was right for him,so there doesn't appear to be any harm, maybe even the opposite

I did look them up-- I know Dilaudid is stronger. The point was, Demerol IM was a new med for me.

So, I triple checked!

Agnus · Dec 13, 2007

This is NOT to minimize any medication error.

The vast majority of errors that happen on a daily basis in every hospital do not result in harm.

This is your first error. That fact that it happened in orientation is not unusual. It is more likely to happen during an orientation simply because of your unfamiliarity of equipment, procedures, enviornment, people you are working with, and the procedure itself.

Forgive yourself and move on. There will be more.

You might feel that there are not a lot of errors where you work. That is only because it is not broadcasted everytime it happens. Even those errors that come to the attention of management are not all the errors.

You might have something like. You give pt A meds meant for pt B. In a great many cases it turns out he takes those same meds. It is still an error. Maybe he takes X for BP and you gave Y. So you end up holding his normal BP med after notifying the MD.

I gave early in my career a narc dose. It was 2X what it was supposed to be. The pt had a good sleep. The dose had been changed (reduced by 1/2) from what it was the day before. I still remember it. Yet no harm was done.

Just learn from your error and move on. Don't beat your self up. There are enough people who will do that for you. ((hug))

When someone tells you what you should have done they are preaching to the choir.

lovingtheunloved, ASN, RN · Dec 13, 2007

Hello
Just posting because I feel so angry at myself, and so very inadequate.
I am a new grad in the ED, off orientation this coming sunday.
Yesterday, while doing conscious sedation on a 17yoM, I under-medicated him with Fentanyl. I had a 3cc syringe, and I mistook the 1/2 cc increments for one cc increments. Long story short, everyone in the room thought I was giving 25 mcgx2, and I gave 12.5mcg x2, and instead of 50 mcg x1, I gave 25 mcg x1.
The procedure was fine, he barely whimpered when the MD reduced the dislocated arm. He had 4/10 pain after, stable Vitals, and no resp distress or desaturations. The post reduction films were fine, and he was d/c'd.
I filled out my first OAR.
It makes me so scared that I'm already making errors and I'm not even on my own yet.
Am I overreacting?

I don't think you're overreacting. I had been a nurse for literally, a day and a half, and gave the wrong meds to the wrong person. Fortunately, my patient was fine, and your patient was fine. I was absolutely sick about it for awhile, but learned from the experience. I guess my point is that we've all made mistakes, and luckily for us, they weren't harmful to our patients, but they could easily have been. I'm so much more careful as a result. I think you've learned from this, and your patients will be much safer as a result.