I made a med error last night that I told the new DON would happen over a MONTH ago!! :angryfire :angryfire
I work 2 Saturdays a month at a ltc.
This is what happened: The unit is Rehab, there were 15 patients 12 were new to me. I got crappy report but figured I could read the charts later. [Which is the way I always learn about my pts.]
It was crazy. I did med pass following the MAR and making sure that every med ordered was the correct one [5 rights]. At 12PM we had a pt go downhill rapidly. He was a full code. We had to get him out of the building fast!! His son and dtr were in the room. I explained that we had to send him to the ER rapidly because of his code status and that we couldn't treat him there.
They transported him to the hospital by ambulance and the ambulance left with red lights and sirens from the parking lot.
I had no lunch, no more than 2 five minute breaks and then at 2:30 I made the error. The IV pump was beeping, because it was almost out of fluid.
I went into the med room and took the bag out of the medical supplies for this patient. I verified that it was hers.[it had her name on it.] I took it down and set it up. I thought that I had saved the next nurse the hassle of having to replace the bag.
I was scheduled to get off at 3PM. Thank goodness I signed my meds when I handed them out instead of waiting until after med pass. We had several things going on at the time.I had given 40mg Lasix IM to a pt. The MAR said that was the med dose and route so I gave it. I did question why I was giving it IM and not IVP.
The Admin. questioned me about the order. She said she had NEVER given Lasix IM. She got the pt's chart out and couldn't find the dr.s order. I showed her the MAR where the order was written but we couldn't verify the order. She finally called the nurse that wrote the order and learned that she hadn't had time to write the actual order in the chart yet. :angryfire
We had one pt with a wound vac on and the Administator and the evening shift nurse were doing her treatment so I stayed on the unit to cover for her and finished passing her meds. I was talking to the ADON about working today when the Nurse came up to me and we went into the nurses station. She told me that I had hung the wrong IV. [On the same pt as the IM Lasix.]
The pt was on D5W 1/2 NS. I hung D5W 1/2 NS with 20meq K+. I told the nurse that I got the IVF from the bag with all the pt's supplies in it. She informed me that the order had been changed 2 days before!!!:angryfire :angryfire
I immediately went to the ADON and told her what I did. I filled out a med error report. When asked what could be done to prevent a repeat. I let them have it. Get rid of old meds or put them someplace way from the other meds. Make sure that ALL old meds are marked D/C or have black lines through them.
This error should NOT have happened. I took complete responsibility for the error I made but I also let them know that I was angry and that policy needs to change.
