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Discussion

Major med error wrong fluid! Need advice please :(

So I made my first major medication error. Lo just feel so terrible right now about it, it just puts my self esteem down that I dread going back to work :(

I feel so stressed out now that I just barely got out of orientation this month (I'm a new grad that recorded 2 mos of training). I wanted to post on this site because I know how much support you can get from other nurses on here. Please feel free to leave comments.

So here was the scenario:

I received my patient in the morning she had a hx of encephalopathy. Her sodium was elevated to 160 so I called the MD and the MD ordered her to go to ICU ( I work in the telemetry floor btw). I also got an order for D5W along with other orders. So I followed the instruction and hung up the fluid. I take my patient to ICU and give report to the nurse. About 30 min later the charge nurse from ICU calls me and says that I hung the wrong fluid! I hung D5 with 1/2 NS instead of D5W! The patients sodium level went from 160 to 165 and she angrily scolded me "you know this could kill the patient right" I stomach just dropped and I felt so alone and scared. :(

I know that this was just a stupid mistake I guess I just looked at the bag and just saw Dextrose 5% and did not see the latter 0.46% NS. I felt so horrible throughout the shift I was just scared something bad was gonna happen to that patient who was already in the ICU. I just felt like I just made the situation worst! The charge nurse from ICU filed a med error report and got further MD orders. I got called in my managers office and she have me a whole lecture about the difference between the tonicity of fluids! Although she did not write me up I still feel so terrible! I just had a bad feeling in my stomach and could not even finish my lunch!

I know that the sodium level was really critical, but I'm just wondering now if something bad could happen to the patient and this could trace back to me. I feel so stressed out and alone right now. I mean this is my first RN job! :( please comment, please no negativity right now I could just use positive words!

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    I understand where you're coming from. The most important thing you need to remember is that you acknowledged that there is something you need to work on to better yourself as a nurse. Please don't let this incident affect you in a negative way. Try to let go of what had happened and retain what you have learned out of the situation to become better. Just be very careful next time and always double check on the medication that you are giving and you're good. I pray for your patient that he/she gets well. Hugs! God loves you...

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    As long as you learn from it and are always more careful then just let it go. I know easier said than done! You are human and mistakes will happen.

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    • Experts

    Deep breath. It's going to be OK. We've all made mistakes and this won't be the last one you will make. No one was hurt.You will learn from this and move on. (((((hugs)))))

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    Do you not have to scan in medications when administering them to a patient?!?!

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    • Experts

    Not everyone does. I don't have to scan stuff.

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    I didnt mean to sound condescending, i was just shocked. Perfect situation to prove how scanning could have avoided a bad situation though

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    • Experts

    We don't scan anything either, except we have to scan our IDs to be able to do ANYthing with our volumetric pumps and to do POC glucose monitoring. Meds - nope.

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    OK - the error was due to a lapse of the "5 rights"... very common. Corrective action needs to focus on the behavioral choice, not the outcomes. After all, the nature of the error would have been the same, even if OP had given ASA instead of Tylenol. It was due to noncompliance with acceptable medication administration procedures - probably skipping steps due to perceived urgency & the fact that OP is a new nurse who has not really internalized the importance of "5 rights". If we're truthful, most of us experienced a similar event that triggered a higher level of awareness & focus on med administration.

    I'm glad that the patient did not suffer harm. I'm also absolutely certain that the OP has learned a valuable lesson & has changed his/her practice accordingly.

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    What you do now will determine how this affects you going forward. As others have said, it's a matter of evaluating how it happened and taking the steps forward to avoid it again. That is what staff will be looking to see, if you crumble apart and turn to jello over this, or if you own it, make it yours, and move forward with cautious confidence. It feels nasty, but that nasty can benefit you going forward. Don't let it crush you and don't let it define you.

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    Mistakes happen.

    From now on you'll be so careful and triple check everything you administer to avoid feeling what your feeling now. You'll be a better nurse and grow from this mistake trust me!

    Feel better! *hugs*

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