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.

[Advocate1]

wow! at first i was hesistant to post about my error at all but now i am so glad i did.

you guys/gals have been great and reading your words of support is really helping me get throught all this.

from the bottom of my heart :redpinkhe - thank you all

[locolorenzo22, BSN, RN]

We all make mistakes...and families don't understand that we are NOT perfect....we do the best we can. As long as the patient lived, and as long as the family is how they are...that's all you can do. The hospital is looking out for #1...themselves! They want action to show that they're fixing the problem....You WILL be more effective now, and triple check everything!....We'll all be there someday...and sometimes, you just can't help it.....hugs...and relax...you'll be ok....

[TazziRN, RN]

The final warning is almost 100% because of the family, I'd bet my career on it. The same thing happened to me last spring: I made mistakes because of the physician, the family was not happy, and I was the sacrificial lamb. Everyone else involved in that case is still working at that facility, but because I was the primary nurse I was tossed out on my tushy. When I asked my manager why the "investigation" was taking so long (7 weeks) she told me they hadn't had a chance to meet with the family yet. Something in the way she said that made me ask her "You're saying that what happens to me will depend on what the family has to say?"

Answer: "Yes"

Since there was no harm and you've never made a med error before, I think a final warning is going way too far, but not much you can do about it. This does mean the hospital will not back you up at all, so be on your toes.

[meownsmile, BSN, RN]

Unfortunatly ive seen it happen too. Family get upset at something done or said at the bedside and someone loses their head. Im so sorry you had to deal with this situation so early in your career. I hope everything goes by without making more interruptions in your life.

I have also seen a major change in the way management and supervisory staff handle families anymore. There is not anything that a family can request that isnt given, nothing they say that isnt believed and nothing any of us can do about it. Its all about patient satisfaction surveys and reports and we will be the "sacrificial lamb" of health care to do it.

[rita359]

I think a good part of the hospitals reaction is because of the reaction of the family. Yes, you made a mistake. Don't know what meds the wrong patient got but apparently nothing to earth shaking. Learn from it. It seems the public is getting less and less reasonable about mistakes. There have been some deadly ones which have been splashed all over the media. We nurses are only human. We will on occasion make mistakes like everybody else even with being on guard against that at all times.

[rita359]

And just another reminder of why we all should carry our own Liability Insurance. Considering how the hospital is treating you and others who posted and lost their jobs over something like this, you would not expect the hospital to back you if a family sued and their insurance would mean next to nothing for you.

[DutchgirlRN, ASN, RN]

Every nurse has made a med error. Be extremely happy that you've learned a valuable lesson over an error that did not cause the patient any harm.

You would have been fired if they didn't understand that the family was being over dramatic but because they did write off the patients bill tells me that they feel they have to have back up by writting you up to have further proof that they treated this incident seriously. Your management and co-workers are behind you. They know the true story. Families like these cause good nurses to leave the profession :angryfire

[queenjean]

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?

.

Did you learn something? It sounds like you did. You changed your practice, and won't let it happen again.

Are you being hung out to dry because the family made a big stink? Sounds like it to me.

If your VP of nursing said she wouldn't necessarily fire you if you get written up again, I'd ask for that in writing. And if you DO get fired over it, and the family goes to the media, I'd go to the media myself, and note that there are procedures for this sort of thing, that you completed them appropriately, that other nurses have made mistakes similar to yours and were not fired.

The BON looks at several factors. One is whether you are likely to make that mistake again. You reported it appropriately, you went to a class to learn how to prevent this error again.

I wouldn't lose another night's sleep over it. Yes, what you did was a serious error. Guess what? No one is perfect. EVERYONE makes mistakes every single day. Our mistakes can be life and death--that makes it tough. But you can either learn from it and move on, or start flippin burgers at the local McDonalds. Being a nurse comes with a lot of responsibility. It's tough and scary the first time that really comes home to you.

My first big error was misprogramming a PCA pump. The nurse who double checked it didn't catch it, either. I gave a pt 10 times the appropriate dose, for two hours. I should have killed her; but someone was looking out for both of us, because the day that I do this, I happen to do it to a drug seeker with an amazing drug tolerance.

What a crappy day that was. I felt very bad for a while. I reported it, discussed it with the supervisor and the clinical specialist. In the end, I helped rewrite some protocols and our computer system, which now prompts every nurse to recheck the PCA 30 minutes after initiation. So not only did I learn from my mistake, but I helped implement procedures that will hopefully help catch it if others make the same mistake.

Hope this helps you feel better.

[purple1953reading]

Sounds like the familly saw BIG DOLLAR SIGNS. The hospital writing off a bill was , in reality, probably, ONLY the part that the family would have been responsible for, and if that patient had Medicare and a supplement, was NOTHING> I was charging ICU and we had a longtime nurse on Step down, who was throwing a big fit about me being in charge and she had been a nurse for 40 years, yadadada. I was on to charge, (as I almost always did) but took care of HER patients, just so as to keep them up to date. Administration stepped in when she said if she had to take the step down patients she was walking out, and said that was up to her, BUT I got moved back to charge in the unit, and her two patients. This is a person WHO always took only vent patients, or comatose patients, as she did NOTHING all day, but charted up a storm( another story) so when I got her patients, I went in with meds, and was told by the coherent patients "IT was nice to get her own meds for a change" Evidently this nurse had given the wrong meds twice to this patient, then went back and gave her her own on two previous days. The roommate had no clue what she took, and just took what was offered. IT IS AMAZING to me that patients have NO IDEA what meds they take, and would not question receiving a handful of different meds then they were accustomed to getting. That is why is it so important for us to give them the meds with the name of the med, and the reason they are taking it. I might do this a couple of times and then ask patients to tell me which is which and why, just a way of educating them. THEY NEED TO KNOW the names of the meds and WHY they are taking them. People who don't will take the wrong meds.

Just as a source of support, I worked with a prnRN who went on to become a travel RN (Always wonder how) and she would come on at 7pm and go to the med room and MARK ALL meds for the shift on EVERY patient she had to pass off as given. (with the appropriate times) DID She give any ? WHO KNOWS, maybe if she wasn't asleep in the bathrrom, where she spent most nights, as she also worked fulltime as a home health and nursing home nurse. I did report her, and the DON said "WE don't know that for sure" and I told her I JUST TOLD YOU

IT always amazes me that the people who own up to their mistakes, or report others for gross negligence, are the ones who seem to suffer. I would bet that you will be very diligent about checking now, and have learned from this. I don't even understand how you can get a final warning if there is no pre warnings, as it usually is a third deal type thing. This will blow over, and they should be proud of you for owning up to the mistake rather than covering it up

[scattycarrot, BSN, RN]

Call me cynical but it sounds to me like the family see dollar signs flashing before their eyes and the management are being excessivly harsh on you because of it. No harm was done and you followed proper procedure after the error and only an unreasonable family would follow through with such vocal complaints. I don't buy this 'well, no harm was done this time but what if it happens again' malarky that they may be using to justify their persistant complaint. People in this day and age are just down right greedy and are just looking for an oppurtunity to sue. As someone else said, ensure you have liabilty insurance as you can bet your bottom dollar that the hospital won't cover your a**!

Every nurse has made a med error (or will!) and it is all about what you take from it and how you grow from it. You did all the right things following the error and don't let this families reaction turn it into something it needn't be.

Good luck and keep smiling!

[DutchgirlRN, ASN, RN]

This will blow over, and they should be proud of you for owning up to the mistake rather than covering it up

:cheers: I second that! Far too many errors are covered up because some nurses (and doctors) are too afraid to take responsibility for their actions.

[UM Review RN, ASN, 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.

I do the same. I'm so paranoid about making a mistake that I bring the entire chart to get the pills and then unwrap the pills and do the last check of the MAR as I give them to each patient. It takes longer for me to do a med pass, but I don't go home worrying.

So guess what? The other day I'm supposed to give Metronidazole (Flagyl) and what came out of the machine? Metformin (Glucophage)! Similar names and both are big white pills!

Of course I called Pharmacy immediately. But still....it freaked me out to think of what could've happened if my patient - normotensive, bradycardic, and euglycemic with poor po intake - got a 500 mg Glucophage right before bedtime.

It can happen to anyone.

I agree that your facility is trying to placate the family. OTOH, this event will only make you a stronger nurse in the long run. I encourage you to forgive yourself and carry on.