Med error during a code

Nurses General Nursing

Published

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.

This might be a silly question but how can you pull out the wrong med from the pyxis?

is it from ''override meds'' where you type in the name of the med?

For example - typed in "Ar" for arixtra but accidentally selected aricept?

Up Vote Up Vote ×
Specializes in Pediatrics.

Override med from the in room Pyxis both med had the 1st 2 letters of the name the same

She was respiratory acidosis one nurse was trying to push bicarb

While I was trying to give my med as pt was thrashing and sz. We were preparing to intubate

There were about 8 people in the room when it happened.

We debriefed the MD actually apologized for bringing stress into the situation. He said he didn't realize how serious it was until after walking in the room and then felt behind and he felt he brought more stress to the situation.

We knew of pts pta then 3 min to arrival medics call saying now code 3. This was a pediatric overdose.

I went back and repeated my steps and it was a slip of the finger, in a stressed situation and I did not stop to verify my 5 rights

Up Vote Up Vote ×
Specializes in Critical Care.

Glad the patient is going to be ok. While the computer scanning is such a hassle it does prevent these type of errors if you use it. Of course in an emergency situation it would slow you down, but it would have prevented this from happening. Just curious what was the med ordered and what was the med given?

Forgive yourself and just remember to slow down and read the label first even in emergency situations and use the computer med scanning if you can!

Up Vote Up Vote ×

Correct me if I am wrong, but in this type of a code situation in the ED wouldn't scanning the med be kind of pointless since this is not a med that was previously ordered for the patient? Sure, you could scan the med, but if all you looked at again was the first two letters you still wouldn't notice the error, and the computer wouldn't alert you to the error because it was not a previously ordered drug for the patient (and the patient likely doesn't have an EMR profile yet?)?

Up Vote Up Vote ×

Thank you for this post. As a soon to be student I eat this stuff up as this is real world insight.

Now I can go look up what the 5 rights are and I will learn an other valuable lesson.

Thank you for sharing.

Up Vote Up Vote ×

Thank you for sharing your experience, as a nursing student about to start my practicum in the ER I will be sure to complete my five rights. I know the situations I will be in won't be as stressful as you were in, almost all situations I will encounter will be new and stressful. Thank you again for sharing.

Up Vote Up Vote ×

So so soooo proud of you for owning up to the error. Fortunately, it didnt harm the patient. Glad you have a good support system!! Keep on trucking, just remember to stop at the check points during the long haul!

Up Vote Up Vote ×
Specializes in Critical Care.
Correct me if I am wrong, but in this type of a code situation in the ED wouldn't scanning the med be kind of pointless since this is not a med that was previously ordered for the patient? Sure, you could scan the med, but if all you looked at again was the first two letters you still wouldn't notice the error, and the computer wouldn't alert you to the error because it was not a previously ordered drug for the patient (and the patient likely doesn't have an EMR profile yet?)?

I think you're right. I'm just so used to using the computer scanning to pass meds, but we don't use it during a code. Luckily it's a step down unit and with the emergency response team codes are fairly rare by us. Of course that is not always the case in ER or ICU.

Up Vote Up Vote ×
Specializes in Pediatrics.
Correct me if I am wrong, but in this type of a code situation in the ED wouldn't scanning the med be kind of pointless since this is not a med that was previously ordered for the patient? Sure, you could scan the med, but if all you looked at again was the first two letters you still wouldn't notice the error, and the computer wouldn't alert you to the error because it was not a previously ordered drug for the patient (and the patient likely doesn't have an EMR profile yet?)?

Yup

The only way it was caught was the recording nurse noticed the label looked different. She was an experienced ER nurse I have been in the ER 2 months, so she knew the color of the labels.

If she hadn't noticed it, it would never have been caught

Up Vote Up Vote ×

the MD actually apologized for bringing stress into the situation >>

:::::thud:::::

Up Vote Up Vote ×
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...
I wish I could "kudo" this times 10 to the 23rd power.

My brother has been a tactical operator and trainer for 25 years. He once hosted me at his special-ops range to practice some tactical shooting... that is, shooting for speed and accuracy... and that is what he preached to me over and over... "smooth is fast" (along with "don't be doing Charlie's Angels on my range" -- which either makes sense or not, depending on your age/experience)... and it proved to be true... as I focused on my motions, my time-to-target-acquisition dropped and my kill-shot ratio rose... in everything, "smooth is fast" and "smooth is accurate."

Up Vote Up Vote ×

Several months past, I made a very serious med error about which I posted on this site (https://allnurses.com/nursing-issues-patient/the-face-of-925954.html). I entitled the post, "The Face of a Medical Error" because I was one of those nurses who was certain that a serious mistake would always be made by *that* nurse and who was astonished to see *that* nurse looking at me out of the mirror.

It tore me up and it shattered my self-confidence. It humiliated me and scared me. It still causes me anxiety. I did everything right... *almost*... and the one thing I missed happened the one time that several other safety stops were inoperable and the holes aligned to let the mistake progress through me into the patient.

I still ruminate over this event and its long-term ramifications are still unknown but it has made me an infinitely better nurse because (a) I recognize my own fallibility, (b) I don't trust the system to block the errors, and © I've learned to slow down to smooth up (to paraphrase akulahawk).

Don't ride yourself too hard... forgiven yourself, make the changes that you need to make, and move on.

You are a better nurse today for having been through what you have.

Up Vote Up Vote ×
+ Add a Comment