Med error . I’m devastated

allnurses Guide · Jan 31, 2019

Calm down. Patient is going to be okay. Right?

Med errors happen, especially in an environment such as the one that you are in now. I once worked on a KIDS psych unit, where we pre poured the morning meds. Each child got their own cup of meds. I somehow gave a kid the wrong meds. Kid was okay. I'm still here. I've made even worse mistakes than that, believe it or not.

mimibrown, ADN, BSN · Jan 31, 2019

Sorry to hear that. Good thing your patient was okay! Med errors are scary, and really cause you to stop and re-evaluate your habits. The best thing you can do is to slow down and pay attention. Review your rights of administration. Make sure you are identifying the correct patients. I try to tell patients everything I am giving them. And don't forget that unfortunately med errors happen to everyone

Try not to beat yourself up too much!

allnurses Guide · Jan 31, 2019

I agree. Very very important to slow.down. Always ask the patient their full name. Most psych units have a picture of the patient along with their MAR.

Anyway, I think you'll be fine. Own up to this error and learn from it. ?

Stephen ww, BSN · Jan 31, 2019

I really do appreciate the support . It’s just that i know it could have been avoided with me just looking at the pt wristband . I think that’s what is truly eating at me

Jory, MSN, APRN, CNM · Jan 31, 2019

Nobody loses their license for an honest med error. Nobody. I have never seen a single disciplinary action because of an honest mistake.

We've all done in at least once. Look on the bright side, I guarantee this will never happen to you twice :).

Chin up!

Ruby Vee, BSN · Jan 31, 2019

2 hours ago, Stephen ww said:
Soo i made a med error on a patient with a name alert . Patient had the same last name as another . A little background about myself I’m an icu who transferred to psych . In ICU I’m use to scanning meds and pt wristband however in psych they pre pour meds and dnt scan . Long story short i gave a pt 70 mg of methadone. A pt who had no history of substance abuse . After about 45 minutes i hear the pct nearby saying a pt is throwing up . NOW YOU CAN IMAGINE HOW FAST I STARTED TO PRAY and beg that that was not my pt. At this point i get up immediately to go see and of course it’s the pt i medicated . I quickly grabbed a vital sign machine and started taking vitals like every 10 minutes. assessing the LOC of the pt. Then it gets worse . The pt sits on the bed then just drops! I mean like DROPS! Now I’m thinking to myself that’s it my Carrer is over I’m done for. But long story short pt was sent to ER and is now stable . But i feel horrible and i know this can come back to me . I really needed to vent because I am seriously shook!

We've all made mistakes. Every single one of us. Anyone who claims they haven't is either lying or too stupid to realize they've made a mistake. I'd rather have the nurse who recognizes their mistake, admits it, and then does her best to take care of the patient. I'd rather work next to them, and I'd rather have them taking care of me.

I once told the wrong family that their loved one had died. Seriously. I was charge in the CCU, and we were told we were getting two patients from the ED. One was named Johnson Thomas and the other was named Thomas Johnson. (I kid you not -- those weren't the two names in question, but they were just like that.).

We got the bed ready and we waited . . . and then we heard a code called in the ER. In due course, I got a call that Johnson Thomas had gone to the Cath Lab and Thomas Johnson had died. But the family was already on the way up to the CCU to look for Thomas Johnson, so could I please let them know because they were too slammed to go looking for them.

Mr. Thomas came from the Cath Lab with the cardiologist, a couple of residents, a procedure nurse bagging and a respiratory therapist pushing a ventilator. We got him all settled in and I went to get his family to come in and see him. While I was in the waiting room, Mr. Johnson's family wanted to know when they could see THEIR loved one. I told them he was still in the ER, and they needed to go back to ER . . . but they'd been back and forth from the ER to the Cath Lab to the CCU waiting room, and they were upset, and the resident and I ended up telling them as gently as possible that he had died. Right about then, Mr. Thomas's family came out of the CCU upset because that wasn't THEIR loved one in the bed . . . .

Our hospital didn't have a name alert policy at that time. They did the next day.

Everyone makes mistakes. What matters isn't that you're perfect because that just isn't possible. What matters is that you do your best for the patient. Sounds like you did that.

Long Term Care Columnist / Guide · Jan 31, 2019

In regards to medication errors, there are two types of nurses: those who have made med errors, and those who will. No one is exempt from this. The good news is, you've learned from yours and will probably never make the same mistake again. Don't be so hard on yourself, the patient is OK and you won't lose your license. Just remember the 5 (or is it 7?) rights and you'll do well.

Been there,done that, ASN, RN · Jan 31, 2019

18 hours ago, Stephen ww said:
I really do appreciate the support . It’s just that i know it could have been avoided with me just looking at the pt wristband . I think that’s what is truly eating at me

Yes. You needed two identifiers. Now you know. Patient is okay, you will be too.

Best wishes.

JKL33 · Jan 31, 2019

19 hours ago, Stephen ww said:
Long story short i gave a pt 70 mg of methadone. A pt who had no history of substance abuse . After about 45 minutes i hear the pct nearby saying a pt is throwing up . NOW YOU CAN IMAGINE HOW FAST I STARTED TO PRAY and beg that that was not my pt. At this point i get up immediately to go see and of course it’s the pt i medicated . I quickly grabbed a vital sign machine and started taking vitals like every 10 minutes. assessing the LOC of the pt. Then it gets worse . The pt sits on the bed then just drops! I mean like DROPS! Now I’m thinking to myself that’s it my Carrer is over I’m done for.

The patient is okay.

And you learned that scanners were never anything more than a confirmation of what one should already know. And that when you don't have one, you keep doing the same thing you should be doing anyway: The Rights. ???

You're gonna be okay, too.

I like the way you told your story, btw. Sorry, but I smiled a little. Everyone has been there in one way or another.

Take care~

pixierose, BSN, RN · Feb 1, 2019

Of course you’re shaken up - it’s because you’re a *good* nurse.

We’ve all made med errors. Those that haven’t, will. We just need to learn from them.

This is a *facility wide* learning experience. Not just you. Never pre-pour, always scan, always always always the 5/7 medication administration rights. In psych some floors tend to get away from this ... our child/adolescent floors do this and it boggles my mind because it’s an accident just waiting to happen (as you found out). On the Geri psych floor we have the WoWs, we pull one at a time from the Pyxis, we scan etc etc.

The facility needs to own up as well.

You're going to be ok.

Stephen ww, BSN · Feb 1, 2019

i really have to say thank you guys because although I’m still going through the motions your comments and advice have really helped me through this . ???? You guys rock .