Med Admin Error

[MedSurg2]

I made a med error at work. I hung a Fentanyl bag for an epidural instead of the Fentanyl/bupivacaine bag for an epidural patient. I feel terrible and so disappointed in myself. I work on a medsurg floor where we rarely see epidural patients and the bags were stacked on top of each other in the med fridge. There are no excuses, but I feel so bad and I'm dreading the debrief meeting. 

[JBMmom, MSN, NP]

Yes, it was an error. But it was also a mistake and mistakes happen to all of us! Hopefully this didn't lead to any adverse outcome for the patient. Was there a scanning tool that didn't pick up the medication change? The debrief meeting is not aimed at blaming you, it's to determine how the error occurred and how future errors can be avoided. Take care of yourself, it will be okay. 

[MedSurg2]

I cannot remember if I scanned the bag or not, but it is a two nurse check off and the other nurse did not catch it either. The patient was screaming in pain and I had been pulled from another room where I was trying to start an IV and rushed in to hang a new bag. The whole situation was rushed. I'm nervous about having to meet with the anesthesiologist, my manager, quality control - it is all very overwhelming. 

There were no adverse effects to the patient thankfully. 

[registerednutrn, BSN, RN]

So most importantly the patient is OK.  Now take a deep breath and step back and look at the whole picture, this sounds like more of a process problem that leads to a med error.  If you did not scan it own that part of the error and state what you will do to prevent it from happening again.  Next is the process part those two meds not have been accessible together meaning they should have been stored separately since both contained fentanyl that was a med error just waiting to happen.  There really should be a RCA so the whole process can be fixed.