Made a Med Error and sick over it!

[Martinette]

I feel like crap. I made a med error last week. The patient was unharmed and my manager told me that it was a systems error etc. and that it wasn't my fault. I still feel like hell. I missed an AM insulin dose. A patient was handed over as being a non-insulin dependent diabetic and when I reviewed her drug chart (she had 3 of them that were handwritten) I missed the order for insulin. Her blood glucose was fine in the morning but went pretty high later on until I figured out she missed her insulin. :trout:

Another patient arrested during the AM drug round and I rushed around doing the medications afterward as I was hours behind. I was med nurse and charge for 13 med/surg/ care of the elderly patients with no care assistants and just back on first day after 2 weeks of holiday. The night nurse who handed over to me didn't really know the patients as she only had the patients for the last 2 hours of the night shift in addition to her 13.

The regular night nurse left in the middle of the night due to sickness so the handover was really incomplete and due to call offs on the day shift as well I ended up on my own and overwhelmed. I called the matron who assured me we were getting another nurse to help out. No one ever should up.

I also had to hang blood as soon as I got out of report because it should have been given on night shift but wasn't..then straight into the drug round and assessing my patients and answering call bells and toileting and bathing simultaneously.

Our nurse managers are fighting to get us more staffing and less cutbacks. My nurse manager told me that it was a bad chain of events that lead to this error and that she knows I do well. I think she is partly right. The current situation in our hospital due to government issues is horrendous. But I also know that I should have looked at the drug chart more carefully and double checked no matter what was happening. Feel like crap. I have been an RN for a decade and should be past this stuff. I can't wait to get out of this place.

[L19P7N9]

The best thing you did was admitted your mistake. You will be a better nurse for it!

[MMorton]

Wow, what a nightmare load of patients and circumstances you were in. Thank God that you caught that insulin order on your shift and corrected it. Your facility is not staffed well enough. THere difenetly is a system error- understaffing to cause a mistake like this. Learn from it and thank God that your patient was not harmed.

[nyapa, RN]

I think I am beating myself because when I went back to look at the drug chart the insulin order was obviously prescribed and I don't know how I didn't see it. Yeah live and learn I guess.

To me, it seems you are beating yourself up because you are someone who puts their all into their work, who likes to "dot the i's and cross the t's ". And you care. You had to hang blood, you had an arrest, you had confusing medication charts, and you had a bad handover.

Its a horrible feeling when you make a drug error. But you omitted a drug, and you picked up. You did not give the wrong drug.

(((Hugs)))

[Martinette]

Thanks for all of your replies. This ward I am working on really scares me and I think it is all the "what if's" that are freaking me out. It's not going to get any better there. In a few months I will be overseas in a new job...just have to stick it out a while longer.

[Nursebarebari]

Girlfriend, if I were you, I will hand over my resignation letter the next day. Caring for 13 patients and answering call bells and given blood is a green light for med errow. You don't need to be in that place, you are a well experience nurse and can find a job anywhere.

Good luck to you

[meownsmile, BSN, RN]

I agree dont beat yourself up. These things happen occasionally unfortunately. We all get that pit in our stomache, that rush of adrenaline because of the thought of maybe having a bad reaction by a patient. All you can do is whatever you can to correct it and then take a big breath and look it as a reminder to be more careful and not get rushed. Kind of like we all get that little reminder when driving and we have a close call, be more careful.

[psalm51]

recently (10/07) attended conference where a an RN is an expert witness for Medicare (the Federal government) (and is also a gerontology NP, PhD, and professor at major university). He described various litigation -- but a common thread that contributed to many of the incidents that resulted in litigation was that the caregiver was unfamiliar with the patient / routine.

sounds as though you went through a "Perfect Storm". there were so many contributing factors. i do understand -- b/c i tend to beat myself up over ommissions of any type -- but i always say "once burned, twice learned. Thank God no one got hurt"

[XB9S, BSN, MSN, EdD, RN, APN]

Thanks for all of your replies. This ward I am working on really scares me and I think it is all the "what if's" that are freaking me out. It's not going to get any better there. In a few months I will be overseas in a new job...just have to stick it out a while longer.

Marinette, I was just reading through this thread thinking it sounds like the staffing levels we suffer with in the UK then noticed you are in the U K:uhoh3:.

You need to fill in an incident form to report the staffing levels and that you had no health care support worker to help you. I assume the medication error would have already been reported but nursing 13 patients with no other help is unacceptable and unless you report it as an incident then nothing will ever change. What if one of your patients had a cardiac arrest with only you responsible for the care of the other 12 patients there would have been far more than just medication missed.

I am curious is this your usual staffing or was there sickness. As far as getting another job, that is easier said than done in the UK at the moment, most places are not recruiting to replace current jobs with most trusts being overspent and having to make cost savings.

[CocoaGirl]

This is just another example of how nurses are expected to get everything done and do it correctly. As long as we continue to have unsafe patient to nurse ratios, be responsible for an entire floors care, charting etc. and be expected to do it with a smile with inadequate staffing, errors are going to occur. WE are NOT super nurses and management should not expect us to be. Frankly I am sick of the mentality that "you can handle it". Management does not want to hear that an error was made due to unsafe patient loads or inadequate staffing. If they or their family member were in the hospital maybe someone would make some changes. I honestly don't know how we as nurses get everything done now. There is not another profession out there that would put up with this BS.

[XB9S, BSN, MSN, EdD, RN, APN]

This is just another example of how nurses are expected to get everything done and do it correctly. As long as we continue to have unsafe patient to nurse ratios, be responsible for an entire floors care, charting etc. and be expected to do it with a smile with inadequate staffing, errors are going to occur. WE are NOT super nurses and management should not expect us to be. Frankly I am sick of the mentality that "you can handle it". Management does not want to hear that an error was made due to unsafe patient loads or inadequate staffing. If they or their family member were in the hospital maybe someone would make some changes. I honestly don't know how we as nurses get everything done now. There is not another profession out there that would put up with this BS.

I am not sure that there is a mentality of you can handle it in the UK which is where the OP is from. There such a huge overspend by most healthcare trusts that there are huge cutbacks on getting agency and bank nurses in. Even when you do request extra staff and it is authorised quite often I have found that these shifts cannot be filled. Where I work the managers are very well aware of the pressure the nursing staff are under as they are often in the firing line to justify nurisng budget overspends. The problem in the UK is one with the NHS and the way it is funded or underfunded would be more acurate and until this changes then staffing levels will not improve.

[leslie :-D]

the conditions under which you work, are begging for nurses to make mistakes.

the staffing and acuity levels, only encourage haphazard errors.

i think you should be grateful, that you only made 1.

only 1!!!

and no harm to the patient!!!

yay!!!

you rock, sister!!!

leslie :balloons::stone

[Mulan]

There is not another profession out there that would put up with this BS.

Isn't that the truth!