Major Med Error

Nurses Medications

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Today I gave my pt. 2mg IV Ativan for anticipatory anxiety for a MRI. Her order was for 1mg, I obviously read the order wrong.

Later in the day, she was difficult to arouse, but her VSS. The following RN elected not to give any form of pharmacology reversal (Narcan), and called the SUP.

The pt. was sent to the ICU and now is vented.

I'm so sick thinking of what I may have done to this woman. Can anyone please tell me of my rights as a RN? I spoke to my SUP and admitted "I read the order wrong". Any advice would be greatly appreciated. I've a stellar Nursing record, and I can't even think of the worse case scenario.

Thank you.

Specializes in Critical Care.

You show no real remorse for the fact that you made a medication error and instead place the blame on factors other than yourself. Grow from this and take accountability for your actions.

"I don't remember" and "short-staffed" are all excuses to place blame on something other than you. Also, talking bad about a coworker to make your event seem somehow less severe shows real poor character.

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You show no real remorse for the fact that you made a medication error and instead place the blame on factors other than yourself. Grow from this and take accountability for your actions.

"I don't remember" and "short-staffed" are all excuses to place blame on something other than you. Also, talking bad about a coworker to make your event seem somehow less severe shows real poor character.

Med errors happen. Should they be looked at with a critical set of eyes to prevent them in the future? Yes, absolutely. However, I see no reason for the soul-searching you apparently want the OP to do, especially for an error like that. This isn't nursing school and the propaganda that goes along with it.

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We all make mistakes. This is one that you most likely won't make again. We all get busy and things happen. Just make sure that you double check orders before giving meds.

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Specializes in Critical Care.

The 2mg of Ativan could not have been the sole reason for the patient to require intubation. If they thought it was that, then they could have given a reversal agent. As for the ICU nurse who creates drama, I will never understand those kind of nurses. They feed off of errors and other things to feel superior to others. I went to a conference this week and was so touched by one of the speakers. Her name is Renee Thompson, and she validates the behaviors going on in nursing that cause problems. You can join her website and she talks about issues such as bullying, etc. It's a horrible feeling when you realize you've made a mistake. You don't need anyone else beating you up because, like me, you probably are already doing it to yourself. Concentrate on the good things you do, the knowledge and skills you possess and know that even experienced nurses make mistakes. When we make a mistake, the hospital uses an algorithm called "Just Culture". This allows them to identify an evaluation of an error. It assesses if there was intent and so on. This gives a fair evaluation of the circumstances and what steps to take for patient safety. We have a process called a "Safety Net", it's where you document errors and so forth. This is not a punitive system. It is evaluated and allows for system changes or changes in practice. It still feels like a "Write Up" but old habits die hard in our thinking. In the past, if I make an error, I offer to go to a class, inservice, or a learning module online. This shows accountability and that you are willing to put your time and effort into taking a positive step from a negative experience. Also, many times, when there are errors, there are other circumstances beyond your control going on at the same time, which can contribute to errors. Good luck and keep your head up!

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Specializes in Critical Care.

ArmaniX Your reply is one of the reasons we struggle as a profession. Very judgmental for a new nurse, it's sad we are breeding such nurses.

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Armani- What are you talking about? She obviously feels remorse.

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Specializes in Acute Care Pediatrics.

It's very easy to cast judgement when you haven't been there yet, you know? Ugh.

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Specializes in Cardiac, ER.

I have to agree with some of the other posts, 2mg of Ativan should not have caused this pt to need a vent. Unless of course this pt wasn't monitored after the fact and spent hours hypoxic and no one noticed. I have had to bag pts after 2mg of Ativan, not as frequently as Valium, but it happens. This is why we give the med and continue to monitor our pts!

Your OP speaks of system breakdown. While being short staffed, extra busy, rushed etc are not excuses to providing sub par care, they are contributors to many errors. These problems should be addressed by the hospital. You mention that you are relatively new to nursing. This is the time you need to develop habits to provide a safety net. This mistake can be a learning experience for you and your coworkers. I work in a busy Level I trauma ED. We are busy and often short staffed, just like the rest of the world. Over the years you learn which corners can be cut and which ones can't. Being unable to waste narcs is unacceptable. While I completely understand the sense of urgency when CT is there to get your pt and you can't find anyone to waste the other 1 mg of Ativan, you can always pop your head into a room, say "excuse me Stacy RN, I'm putting 1 mg of 2 in the sink, get with me when you are done to waste in the pyxis", then dispose of the Ativan in the sink. This does two things for you, obviously you now have a witness for your waste, but you have also spoken your order out loud "I'm giving 1mg of Ativan and wasting one",... you will catch mistakes that way!

I'm not sure what type of floor you work, but I hear c/o ED staff frequently voicing frustration that this floor or that floor cant take a pt because they have IV narc pushes ordered. "They are nurses, they can monitor a pt after IV fentanyl". Well, yes they can, if they have the equipment and access to their pt. I started my career on a cardiac floor. While we had wireless telemetry, we had no way to monitor SPO2 or BP without being in the pt room. I might have 6 pts spread across the floor. I couldn't see them without going into the room and the only monitoring I could see outside the room is the tele. This made it unsafe to push certain meds unless I was able to hand off my other pts to stay in one room to monitor after pushing the meds. This wasn't going to happen, therefore we were not allowed to puch several meds on the floor.

My point here is learn from your mistake. Use the resources available in your hospital to make meaningful changes to reduce mistakes. Create safe habits that you never veer from! These habits will become second nature and help to keep you and your pts safe!

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Specializes in Oncology.

IV Ativan is frustrating. I give a ton of it. I usually give 0.25-1mg. I've never seen it packaged anyway except a 2mg/1ml syringe/Carpuject.

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The reason I tittle it major, it because I might get fired from it. I'm new to the process of med. errors, and the intention of this post was more about my rights as a RN.

The pt. was 75 y-o, which I've given that amount to pt.'s that age several times, I believe there is some underlying cause.

Before my hospital calls me, I was hoping to gather some information regarding anyone who's made a med error and/or dealt with admin.

Thank you for your time.

My experience is that in most cases, unless the order was particularly egregious (e.g. you gave an opiate-naive patient 10 mg of hydromorphone and the patient died) it's unlikely you would be fired. Hospitals are generally starting to recognize that many med errors are not due to the nurse's personal failing, but rather to a breakdown in the system that allowed the med error to occur. Maybe you were distracted. Maybe the workload was too heavy. Maybe there was no proper MAR created and you were working from a poorly hand-written one. Maybe the medication vials looked too similar or the proper dose wasn't available. A med error is a call to examine the system and determine underlying causes and if there is a way to make the system safer.

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Specializes in Pediatrics Telemetry CCU ICU.

Now,that's what scares me also that she did not advocate for flumazenil, coming from a RN who gave a complete bottle of insulin thinking it was protonix. I digress.

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Well, if they fire you, then they must fire her. They must treat everyone equally. Her giving a whole bottle of insulin, thinking it was Protonix was a med error and she is still there.

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Specializes in Critical Care.
ArmaniX Your reply is one of the reasons we struggle as a profession. Very judgmental for a new nurse, it's sad we are breeding such nurses.

Because I expect that when we, as professionals, medicate a patient we take the time to monitor our own actions and take accountability for our mistakes.

The OP made a med error. Did 2mg of ativan send a patient to the icu? Probably not. The issue is the OP made a medication error and instead of looking for ways to prevent this in the future we are placing blame on everything but the one person who could've prevented the error, the nurse.

Being short staffed and not having someone to waste 1mg of ativan with does not mean we waste it in the patient. This patient was not crashing and this was not life saving ativan. The nurse was not paying attention and gave a full dose. They are not the first to overmedicate a patient.

Instead of focusing on how the OP could prevent this error in the future they made the choice to bad mouth another "drama" nurse who allegedly gave a full bottle of insulin IV push. This is all a method to make the med error seem less important to the OP. "I did this, but at least I didn't do this" mentality.

I am not the problem with our profession. The problem is those individuals who minimize their own actions and don't realize that the next mistake could cost a patient their life.

I'm not saying nurses should be fired or scolded for making medication errors. I'm saying that when we make an error, we need to own it and make sure it doesn't happen again. Throwing another nurse under the bus to save ourself or make us look better is not acceptable behavior.

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