Med Error Advice...

Nurses General Nursing

Published

I work as an LPN at my hospital emergency department. I am a new nurse (5 months) and stared out in the ED. On my last shift we had a patient that had just returned from radiology. I was helping the xray tech getting him hooked back up on vitals monitoring and I reattached his IV line and unclamped the line. I went back to my desk and was working for roughly 5-10 minutes when patient's RN came and asked me if I had started the Vancomycin in room 3. I said that I hadn't, thought for a moment and realized I had hooked this patient back up to his bag of fluids. She told me that it was Vanc and I had just bolused the patient. My heart sank! I did not ask the RN or even think to check the bag. She told me that you don't bolus Vanc, which I know that it has to be infused roughly over 1-2 hours. I immediately called my supervisor to let her know what happened. I also filled out an incident report. I monitored the patient for any adverse side effects for the duration. Thank God their weren't any. I made a mistake and owned it. But at the same time, I feel as though I wan't COMPLETELY to blame for this error these reasons: 1. vancomycin must be infused with a pump and that the line must be on a pump when the bag is hung. The RN did not attach a pump to the infusion line or on the IV pole. The nurse said it was sitting on the cabinet. 2. At our facility, as I am sure with any other, when you mix a med in a bag of fluids you must attach an orange sticker to the bag indicating what has been mixed. There was no sticker on the bag of fluids indicating any drug had been mixed with it. I know I made a huge error and I am so thankful it did not harm the patient. But am I wrong in thinking there were other aspects to this as to why the error occured?

Great advice!!! Thank you so much!

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Specializes in ED, Pedi Vasc access, Paramedic serving 6 towns.

Just wondering if the RN involved got reprimanded or had any consequences? I hope you make out ok!

Annie

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I'm really sorry you have to go through this...good luck!

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The meeting with HR went VERY well! :yes: I will have an RN preceptor (she is my favorite to work with) for 4 weeks in doing all her med administration while I shadow her. My supervisor, HR director, and nurse educator told me over and over that they want to see me succeed. And I want to succeed so my patients and fellow nurses trust me. I honestly thought I would no longer have a job. I feel so relieved that I still have my job but more so in the fact I will also be getting the remediation that I need to keep from making mistakes in the future. The only issue we discussed (that was offered up to me) about the other nurse was not only was the bag not labeled but that it was only diffused in 250ml of NS when it should have been diffused in 500ml NS. I did not ask any questions as to any repercussions of the incident other than what I was responsible for. Thank you guys for all of your advice and support!! I really appreciate all of you!!!

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Excellent!!!

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The meeting with HR went VERY well!
That's wonderful news - very happy for you!
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Specializes in Med-Tele; ED; ICU.
The meeting with HR went VERY well! :yes: I will have an RN preceptor (she is my favorite to work with) for 4 weeks in doing all her med administration while I shadow her. My supervisor, HR director, and nurse educator told me over and over that they want to see me succeed. And I want to succeed so my patients and fellow nurses trust me. I honestly thought I would no longer have a job. I feel so relieved that I still have my job but more so in the fact I will also be getting the remediation that I need to keep from making mistakes in the future. The only issue we discussed (that was offered up to me) about the other nurse was not only was the bag not labeled but that it was only diffused in 250ml of NS when it should have been diffused in 500ml NS. I did not ask any questions as to any repercussions of the incident other than what I was responsible for. Thank you guys for all of your advice and support!! I really appreciate all of you!!!

I'm very pleased that your organization has chosen to have a culture of safety - whether they realize that or not. In such a culture, errors are viewed as opportunities to be better and better, not as something to be hidden and punished which is so often the case. I've always been of the mindset that a nurse who's actually made a med error is later a safer nurse in practice than one who hasn't only because it's now a reality to them rather than still a hypothetical. Perhaps I say this as one who has made a serious med error but if we accept that experience makes us better then even bad experiences still help us -- if we're willing to learn and grow rather than blame and defend.

I'm really happy for you.

Just as a point of clarification: The medication is not "diffused" in the solution, it's reconstituted.

Again, learn from this... take the opportunity for growth... and be great!

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Specializes in Oncology (OCN).
I'm very pleased that your organization has chosen to have a culture of safety - whether they realize that or not. In such a culture, errors are viewed as opportunities to be better and better, not as something to be hidden and punished which is so often the case. I've always been of the mindset that a nurse who's actually made a med error is later a safer nurse in practice than one who hasn't only because it's now a reality to them rather than still a hypothetical. Perhaps I say this as one who has made a serious med error but if we accept that experience makes us better then even bad experiences still help us -- if we're willing to learn and grow rather than blame and defend.

I'm really happy for you.

Again, learn from this... take the opportunity for growth... and be great!

THIS!!!! A million times...this!

As someone who has also made a serious medication error (with chemo no less, along with a group of about 10 other colleagues) mistakes can be an opportunity to make you a better nurse and to correct problems within the system that led to the error in the first place. It all depends on how you and your organization treat the situation.

Best of luck to you, brockclan3!

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Specializes in Med-Surg., LTC,, OB/GYN, L& D,, Office.

best wishes for your success...

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Specializes in Transitional Nursing.

A good rule of thumb is that if you didn't prep it and hang it, you don't give it. Ever. Next time, just unhook it, flush it if needed and let the RN know there is a bag of fluids hanging.

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Specializes in Med-Surg., LTC,, OB/GYN, L& D,, Office.

You're sort of a little late coming to the thread but it is very enlightening...you may want to go back and read through top to the conclusion....i won't hint at it so I don't ruin it for you...

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Specializes in PICU, Pediatrics, Trauma.

There are ALWAYS more than one cause for mistakes. You already stated yours and You are correct that the fact that the bag wasn't labeled and no pump contributed. This is why we have the safety measures of checking, checking, and checking....Also, once again, rushing and feeling pressured also contributed. What I learned, is that when it comes to Meds, and this includes fluids, you should never rush or skip safety check steps. That's all we can do under the short staffing situations.

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