Med-error & down n the dumps

[Advocate1]

:oWell I made my first (and hopefully last) med error .

I gave wrong meds to the wrong patient. The meds were NOT high risk medications. To make a long story short although I asked the name I never looked at the ID band. Nothing bad happened, the pt was fine, I reported it immediately.

The bad part is the family- I understand their position b/c I was in their position once too, but when I asked to apologize to them they said they didnt want it. They are going to JAHCO and Dept of Public health and also threatened to go to the media. The hospital wrote off their bill

and is still having "meetings" with the family.

I felt horrible and havnt been sleeping well for over a month. I have gone to a PT Identificatio class, have been asked questions regarding the incident almost daily, and and really beginning to doubt myself.

I have a lot of support and my coworkers have been great, saying everyone makes mistakes- be glad nothing happened, and learn from it.

I have learned & believe me I check ID bands w every med pass. But now i have been given a "final warning". I have never been written up before. Actually, i have been an RN for

I asked my mgr if things would be different if this happened to a different family and she didn't give me a straight answer. Other RNs have made med errors and didnt recieve "final warnings" .

I spoke with the VP of nursing and she said she believes in me and knows I wont make a med error again but they had to write me up. She also said that if anything ever happened in the future that I wouldnt be immediatly fired b/c she would consider the situation.

So i am wondering what to think- am i being given a final warning b/c of the incident or to appease a very difficult family.

I know I am a good RN and I also know I still have much to learn and I have learned a bundle from this alone. I am just being so hard on myself now and I can't help from beating myself up over this day after day.

for those that have made errors how do you move on?

I know the post was long - I just needed to get it off my chest.

[bassmasterangler]

Sounds like the write up is a reaction to a family demanding action. Say the media did get involved, at least the hospital can say you were disciplined and are undergoing re-training or whatever...if they didn't write you up, they would look as though they don't care.

Don't sweat it, you still got a job don't you?

[Advocate1]

I am still working on my floor-

maybe ur right- Thanks for the support

[Virgo_RN, BSN, RN]

I made a med error in clinical once. The ordered dose was 100mg, but the tablet that pharmacy had placed in the patient's med drawer was 150mg, and despite checking the Six Rights, I did not notice the discrepancy until after I had given the med. My heart stopped when I realized my mistake, and I went to my clinical instructor immediately. I was on the verge of tears, fearing I had harmed the patient and that I would be kicked out of the program. My clinical instructor did not berate me; she went with me to check on the patient, she filled out an incident report, and she praised me for coming forward with my mistake. She said that this shows that I will be an ethical nurse, and that we need ethical nurses. She said how many would have tried to hide their tracks, but I came forward and faced up to it, and that spoke of my character. I have not made another error since, and I am extremely careful with meds, double and triple checking everything.

I wish that your patient, their family, and your facility would have realized that for you to come forward with your mistake shows a great deal of maturity and strength of character instead of reacting in a punitive way. It sounds to me also that there may be some room for process improvement that can prevent similar mistakes by other nurses further down the road.

I'm glad no harm came to your patient, and it seems that you will be more careful from now on. Best of luck to you.

[Virgo_RN, BSN, RN]

I just want to add a couple of helpful (I hope) tricks that I have used. Does your facility print out inpatient labels for each patient, with their name, birthdate, account number etc.? I used to stick one of these over the top of the med cup to remind me to verify patient identification before giving the meds.

Another thing I do is, I take the meds into the room still wrapped. As I unwrap each one, I tell the patient the name of the medication and the dosage. This gives the patient the opportunity to confirm that this is a medication that they take regularly, or are familiar with, or if it is a new medication for them or something they've never taken before. If the patient doesn't know their meds, their family members often do. Not only does this help to be sure the right patient is getting the right meds, but it also provides opportunity to do some teaching if warranted.

I hope that's not too basic. Hope it helps.

[skittlebear]

I don't think there is a nurse out there who hasn't made at least one medication error in some way. I've heard of errors far worse than yours. In fact, the same incident as yours happened just last month at my facility...but the person receiving the wrong medications had a lot of "MAJOR" meds involved...seizure, HTN, and Glucaphage, to name a few. The nurse had to fill out an incident report involving the error, call the doctor, etc. After that, nothing was said. Everyone knows mistakes can happen at any time. Hopefully the family members will see that no one, not even nurses, are perfect and do make mistakes.

[Scrubby]

I think a 'final warning' over this is extreme. Yes you made a mistake which COULD have been far worse. However, instead of encouraging and supporting you to improve you medication skills they threaten your position by overreacting. This is one of the reasons why nurses DON'T report medication errors because they fear the blame and repercussions later on!

If i were in your shoes i'd be calling the nurses union to get this final warning dismissed and i would probably look for another job where the NM and CNC stand by their nurses NOT catering to hysterical family members!

[kdblueey]

I know that regardless of how many nurses tell you that you did the correct thing, that your only human, that mistakes happen, etc., etc., etc...your STILL going to beat yourself up. Your human, it happens, unfortunately, it happens with nurses because we have so much stress placed upon us, by the public especially. For some reason, the public thinks that nurses are almost GOD-like. We are seen as #1, when it comes to who the public trusts the most, even above doctors (this was taken from a 2007 recent gallop poll). Think of all of the 'thoughts' that are in our heads at any one given time when we are taking care of our patients. Not only are we thinking of all of the things that our patients need, we are also thinking about our own personal lives and what our own family needs.

I worked at a hospital in Cincinnati, Ohio (as a traveler), that did computerized charting. At the time, it seemed like a very, lengthy process to just go in the patient's room to give them their medication, but as I look back at it, it seems to be the ONLY safe way to give a patient the correct medication. Everything is checked PRIOR to the actual administration of the medication. If something is wrong, the error is found BEFORE the mistake is made. It's too bad all hospitals are not computerized, as this seems to be the safest way to prevent errors.

Please keep in mind that you ARE human, you WILL make mistakes (in every facet of your life), and that only WE can forgive ourselves, and learn from our mistakes. You mentioned that you are a good nurse. Keep thinking those same words whenever you start to doubt yourself in the future.

Hope this helps. Hang in there and keep doing the great job that you seem to be doing.

Kathy, RN

RN Traveler

:redpinkhe:innerconf:heartbeat

[Tait, MSN, RN]

First off :hug:

I have made two, I guess I would say, major med errors in my last four months of nursing. Luckily for me both of mine some how actually managed to benefit the patient. One was a double dose of Flexeril (forgot to cut the pill) and the other was giving a Temazepam to a gentleman who didn't have it ordered (I sat with my breath in my chest all night watching him brady in the 50's however he had lots of heart meds and was 91, he woke up to tell me he had never slept better, and his doc prescribed it for him the next day for his stay).

I also had a wonderful nurse that I really look up to at my old job tell me she also did what you did, giving the wrong meds, but she mixed up two people in the same room.

You are correct to remind yourself that you are a good nurse, because you are. The sheer act of even stressing about giving the wrong meds is a trait of that.

I am sorry the family had to be so harsh, but we can all understand their concerns. Many families are already on the outside loop of health care and when they hear "med error", no matter how minor, they think of the awful 20/20 or 60 minutes they saw where someone killed somones child with an overdose of XXX drug.

It's time to set it aside and get some sleep my friend. Your patient is safe and fine. The family will get what they want, and if your facility makes you uncomfortable or makes you feel your job is threatened just stand your ground, continue to be honest and caring and let the cards fall as they will. Don't stress that you won't get another job, because you will. Just stay honest and true to yourself.

:hngon:

[Music in My Heart]

I noticed that you're less than one year into your career. Perhaps part of the reason for the 'final warning' is that you're still pretty green and they're trying to emphasize to you the seriousness of what happened. You said that the VP indicated that another mistake would not result in automatic termination which softens it a little bit.

I'm glad for you and for your patient that nothing serious resulted from the error.

What's done is done. Keep working at letting it go and move on with your life and your career. Though perhaps the pt family won't forgive you, forgive yourself.

[Sabby_NC]

Bless your heart.

Hang in there I am sure things will get better and you have certainly learnt from this.

I wish you all the best in your nursing career (hugs)

[sharlynn]

I think a 'final warning' over this is extreme. Yes you made a mistake which COULD have been far worse. However, instead of encouraging and supporting you to improve you medication skills they threaten your position by overreacting. This is one of the reasons why nurses DON'T report medication errors because they fear the blame and repercussions later on!

If i were in your shoes i'd be calling the nurses union to get this final warning dismissed and i would probably look for another job where the NM and CNC stand by their nurses NOT catering to hysterical family members!

I agree with Scrubby. Families can really cause problems sometimes. I think I'd be looking for another job, too.