Med error during a code

[LoveMyBugs, BSN, CNA, RN]

I made a med error tonight.

I am feeling sick about it.

PT came in code 3 after having a sz in route

Pt was becoming combative and started to sz again respiratory acidosis.

MD ordered meds. I pulled the wrong med from the Pyxis

I looked at the 1st 2 letters of the med on the bottle while drawing it up.

The meds had the same concentration mg/ml

I didn't have a second RN verify.

There were 2 other nurses in the room, one charting one also giving meds.

I didn't stop.

I didn't verify my 5 rights....right drug

Pt was sz

Error was caught immediately by the charting nurse.

MD was in the room.

Pt is going to be okay

We debriefed, MD said the error did not hurt pt, did not cause harm.

My team was great, they hugged me, one cried with me as she had been in my situation before during a code.

Lesson learned even in an emergency, even if you are 100% sure you have the right drug. Stop make someone verify.

[RobBSNRN]

Wow, scary...

I'm glad the patient will be ok and that all your co-workers were understanding. Could have been much worse for everyone but during an intense high paced situation who couldn't envision a mistake happening once a career?

[xoemmylouox, ASN, RN]

It happens. It is tough in those emergency situations. We all make mistakes. Forgive yourself and just always remind yourself no matter the situation to ALWAYS do your 5 rights. It sounds like you have a good group of coworkers who are there to support you regardless. That is priceless.

[iPink, BSN, RN]

Sorry to hear that and glad patient was ok. Do you not shout out the med during the code to verify? The charting nurse seemed to be the best one to second verify med that was shouted out?

[PMFB-RN, RN]

It sounds like you are beating your self up too much abut it. Take it as a learning experience, learn your lesson, let your mistake make you a better nurse, drive on.

We do not have a second nurse verify our code meds, but the standard practice is for the code leader (not always a physician in my hospital) to verbally order the medication and for the medication nurse to repeat the order and dose and the code leader verifies. We have either a pharmacist (day shift) or RN (night shift) standing at the crash cart handing drugs to the med nurse.

[amoLucia]

(((HUGS))) to you.

[akulahawkRN, ADN, RN, EMT-P]

First off, I'm glad that the patient will be OK. That's the number one thing. I'm also very glad that you have learned a very important thing. You should never be so rushed that you don't do the checks. Even when the patient is thrashing about, taking an extra 3 seconds isn't going to make one whit of a difference to their outcome. When you get that order, slow down a second, pull the drug, make sure that the right drug is what you have, and so on... just like they taught you in school. While I'm not saying go at a snail's pace, remember that just like they teach a lot of people when speed is of the essence, slow is smooth, smooth is fast. You would be amazed at how speedy you become overall when you slow down just a little bit to gain some smoothness...

Lastly, I'm super excited to hear that you have a very supportive team around you and that you all hopefully have learned something along the way. In previous jobs I've had people on both ends of that support spectrum and it's just simply awesome when you have such a supportive team to work with.

[traumaRUs, MSN, APRN]

Codes situations are stressful. Mistakes DO happen, even under the best of circumstances.

You know what led to this error and you know how to fix it. Don't beat yourself up about it.

Take care...

[That Guy, BSN, RN, EMT-B]

I made my first med error during a pediatric RSI. You bet I learned my lesson and do everything I can not to do the same thing again. Just take it as a learning experience, be glad they were ok and apply to the future.

[The Bell Jar]

Like another poster said, don't beat yourself up about it. You sound like you have very supportive co-workers.

[studentnursemon86]

I made an error once. I grabbed the wrong patient label to run a stat venous blood gas. We caught it right away and I ran it under the correct patient. It didn't cause harm, but I was also in tears.

We start meds next semester in nursing school. I'm scared.

I'm glad your situation didn't result in harm to your patient. It is hard in code situations when things need to be done immediately to save someone's life.

[emergenceRN17, ASN, BSN, RN]

Glad you have wonderful co-workers! =)