I made a med error and feel so disappointed with myself

Davey Do · Jan 28, 2020

32 minutes ago, barbzRNBSN said:
should’ve hit accept first AND THEN give them. if i would’ve done that then i never would’ve made this mistake.

I dislike all the hoops we have to jump through with the computer system when administering medications, but I sure do appreciate it. Utilizing the computer system has prevented me from making some med errors.

So, barbz, you're human, you made a mistake, acted like a prudent nurse thereafter, and ingrained a process.

You have my admiration and respect for your actions in dealing with this situation!

Just me. · Jan 28, 2020

There are different online sites, for some reason the FDA one didn't give me much information.

The hospital pharmacy should have the packaging insert for the drug.

We have all made medication errors, even if we didn't know it. And experienced nurses make errors too. I have made them just like everyone else. A seasoned nurse I work with asked me if I needed help, I said yes. She gave bentyl iv instead of im. Similar risks. Use it as a learning experience. I am sure you will pay more attention next time.

EDIT: I don't even give phenergan anymore except suppository once in a blue moon, next time you have a drug you are not familiar with: look it up in the old handy drug book/or download an app or call pharmacy. One pharmacist calls me by name when I call.

adventure_rn, MSN, NP · Jan 28, 2020

It's going to be ok.

Realize that all of the feelings you are experiencing are completely normal, and they're going to get better. True, all nurses make mistakes at some point, but that doesn't make it suck any less when it happens. I know that feeling of getting a knot in the pit of your stomach, that guilt and frustration from knowing that you know better. I've seen coworkers with decades of experience in tears over mistakes, even when they didn't end up causing any patient harm. I'll say it again, what you're feeling is totally normal. Don't feel bad about feeling bad; it's going to get better.

You can use this as a learning opportunity for the future. It's unfortunate, but I've found that the best learning opportunities in nursing tend to come from the most uncomfortable experiences (i.e. if you've made a mistake, or somebody has pointed out to you how you could have done something better).

My red flag in the scenario was that you were giving an abnormal dose relative to what you're used to seeing. Next time, if you notice that something about your med order seems off compared to the norm, it's a good idea to investigate further. (I know, hindsight is 20/20, so it's much easier to say that now after the fact than to catch it in the moment.)

I wouldn't beat yourself up too much about the Epic thing--unless Epic would have given you an 'alert' message, there's no reason to think that accepting before or after giving the med would have made a difference. I do think that being distracted by learning a new system could have easily played into this error.

If it makes you feel any better, I think there were a few 'systems' issues that set you up for this error. First, as I mentioned, you were probably distracted with the new MAR.

Second, it's really weird to me that they'd order IM phenergan for a patient who has IV access. You give IV phenergan all of the time, so it's unsurprising to me that your brain might assume the dose should be IV (because why wouldn't it be?) I wonder if this was an oversight by the ordering provider; sure, you could have caught this discrepancy and asked, but they should have caught it at the time of ordering, too. If there was some specific reason they wanted it given IM over IV, it would have been ideal for them to give you a heads up.

All of that to say--even though this was an error, there's a reasonable series of steps to understand why it occurred.

Please try to be kind to yourself. This doesn't mean that you're a bad nurse; if anything, learning from this experience will make you a stronger nurse.

"nursy", RN · Jan 28, 2020

I know that saying everyone makes mistakes doesn't make you feel any better. But, it is the truth, and a worse truth is that you will make another mistake somewhere down the line because you are human. You asked if anyone else has ever done anything similar......EVERYONE has done something similar, or made a mistake somewhere. The good thing about this particular scenario is that you caused no patient harm, and you learned a valuable lesson. One of the most difficult things we face is, not only beating ourselves up, but feeling embarrassed in front of our coworkers who we assume are talking about this endlessly and think we are stupid. Except, they forgot about it a long time ago, because they have plenty of other stuff to worry about.

Sour Lemon · Jan 29, 2020

On 1/27/2020 at 6:03 PM, barbzRNBSN said:
help so i’m a fairly new nurse. i’ve been on an ortho/medsurg unit for a little over a year. i was giving phenergan 6.25mg to my patient. it was ordered IM but i gave it IV. i realized right away after i did and told my clinical coordinator who called the pharmacist. they said what could’ve happened was vein extravasation but said it would’ve happened immediately. the IV site was fine, no redness/swelling. patient denied any pain. VS stable. NSS was running only at 80ml/hr and the patient had an 18G IV so it was diluted through the tubing.
my hospital is new to the epic system so i’ve been scanning the meds, giving them, then hitting accept/complete when really i’ve should’ve hit accept first AND THEN give them. if i would’ve done that then i never would’ve made this mistake.
like i said the patient was absolutely fine, i notified the DR and he ordered an EKG which was fine. but i just feel so stupid and so guilty. i should’ve realized because ive giving phenergan IV piggyback a few times but i just saw how low the mg was and thought it was fine IV push.
anyone do anything similar ? help i am just so mad at myself for this

I remember how horribly lonely I felt when I made a medication error. I wanted to hear that everyone in the entire world had also made one, but most people don't care to broadcast their failings.

So ...I'm just here to say that I have screwed up too, and to offer some support.

ClaraRedheart, BSN, RN · Jan 29, 2020

It happens. Mistakes happen. Find a way, or a process that you can do so that particular mistake won't happen again. I gave Imitrex IV once. The patient was fine and it worked. That being said, 2 years later when I read that it was a subQ injection and should never be given IV I was flabbergasted and ashamed. It could have stopped her heart. If you're giving a new med, look it up. Better to be safe than sorry.

ruby_jane, BSN, RN · Jan 29, 2020

Hospitals (and indeed, some other nurses) have a low tolerance for medication errors we make.

Hospital nurses also occasionally appear to have a low tolerance for those of us who are new looking up the meds with which we're not familiar. My preceptor in the ICU openly mocked me for doing so but that's how we LEARN.

Hang in there! You missed the medication "right" of route but you did everything correct after to recover and make sure the patient was safe. This will make your practice safer. Best of luck!

Music in My Heart · Jan 29, 2020

Don't stress on it and don't repeat it.

Phenergan is a terrific antiemetic and IV administration is, in my experience, more effective and more rapid in the relief of nausea... IV is the preferred route *if* you have a patent IV in a moderate-to-large vessel. Many docs would gladly change the order from IM to IV if requested by the nurse.

Obviously you took an unrecognized shortcut by not verifying the route in the MAR prior to administration and that is your fundamental error, but one which is simple to never repeat. Had you more experience you would have recognized that phenergan is one of those meds which can go either way and is a high-risk vessicant when given IV. Of course, now you have a bit more experience than you did.

Don't beat yourself up over it, especially since it was a harmless error. Learn from it, change your practice appropriately, and go forth to become and expert nurse.

For what it's worth, I have made a similar error in the distant past as well as a totally different and much more serious med error and yet here I am as a highly experienced and much respected critical care and resource nurse.

As with all errors, the appropriate response is to understand the root cause and to make appropriate changes.

♪♫ in my ♥

**CommunityRNBSN, BSN, RN** · Jan 29, 2020

And now everyone at your work will know that you are honest and dependable. Because you didn’t cover it up or try to make it someone else’s fault. You showed that your first concern was for the patient, not for yourself. Good work!

**CommunityRNBSN, BSN, RN** · Jan 30, 2020

When I said “everyone will know” I meant your boss! Not your coworkers.

Tweety, BSN, RN · Jan 30, 2020

We live and we learn from our mistakes, but first we have to beat ourselves to a bloody pulp and relive and relive and regret despite the support, despite knowing we're only human. It's just how we do it.

Been there and done that.