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Stephen ww Stephen ww, BSN (New Member) New Member Nurse

Med error . I’m devastated

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You are reading page 2 of Med error . I’m devastated. If you want to start from the beginning Go to First Page.

you admitted the error and you saw the patient got treatment, yes you are human and made an error but you owned up to it and it will never happen again

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So what did you learn from this?

What changes in your practise will you make to prevent this from happening again? That is what you should take from this. 

Everyone makes mistakes. That is why the eraser, white out and the back button all exist. 

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1 hour ago, Stephen ww said:

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 . 

Two more things:

Let this be a lesson that empowers you to be discerning about what you do and don't do, regardless of what others do and don't do. Aim for that idea of being a prudent nurse and making prudent nursing decisions. So when you see everyone else pre-pouring meds or not conscientiously practicing the "rights" of medication administration, you will feel empowered to act upon your voice that tells you that is not prudent nursing practice and that you are allowed, empowered, and obligated to do things differently.

Lastly: After you've burned your lessons into your brain, you have to let the self-deprecation go. Perseverating with negative self-talk is a distraction in and of itself. Take the lessons, leave the rest.

 

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You didn't try to hide it, you followed up, and did your best to monitor/stabilize your patient before he was sent to ER. Sounds like pre pouring meds is common practice at your place like most psych facilities. Don't be hard on yourself and I'm certain you won't let it happen again.

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Med errors/ almost med errors happen everyday no matter what system is used. nurses just need to slow down. I've had my share of those but not to the extent of what happened to this patient. when i'm doing meds, i'm constantly distracted by family or patients wanting something. this can mess you up big time and it almost did to me last month. 

Good luck, I hope everything will work out. 

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Obviously very upsetting, but at the end of the day, if the patient didn't die or suffer permanent disability, it's just unfortunate vs. life altering.  Be relieved and learn from it (as I'm sure you have).

And I agree with Dy-no-mite Nurse1, distractions and constant bare bones understaffing are really a problem as far as med errors are concerned.  Rush, rush, rush, pulled in a thousand directions.   Patients First in 2019 means minimal RN staff, no secretary, no transport, and one tech for a whole unit.  Any complaints and we are told to huddle and work as a team. 😡

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Meds errors can happen to the best of us. However, it is quite surprising that the entire hospital is not using bar code medication administration (BCMA). Research has shown that BCMA has decreased medication errors by 75%. The BCMA only works if the nurse does not do any workarounds. 

Maybe you can take this opportunity to discuss with the Quality department about including BCMA in the psych department. Pre-pouring meds are a disaster waiting to happen. Good luck and keep your head up!

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Glad your patient was ok and be glad that this error was not fatal. We have all been there. Looking into most mistakes, a lot of the time it's not just the nurse, but the environment that leads to medication errors. Systems in place in that unit, constant interruptions from drs and family members, the list goes on.

Is it possible to change to preparing each patient's medication in front of them and not everyone's all at once. To me this is just an error waiting to happen. I'm sure you're not the first nurse in tgat situation to make a mistake, but honest enough to admit it.

The worst mistake I made when I started nursing was not checking blood results before giving out meds. Patient was in renal failure and gave them potassium. Felt terrible and they had to get dialysed they ended up ok, but was mortified. It's made me a better nurse as I check absolutely everything before giving meds etc. 

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Psych is a nightmare to pass meds in when you're not used to it. The patients don't stay in their rooms, they don't keep their armbands on, they call themselves "Diana Ross" and "George Washington" (on the rare occasion they use a first and last name), and there's usually someone screaming in your face about something ...because the last medication doses given have started to wear off.
And I could almost swear that half the patients are tall, thin, disheveled men that can walk but use a wheelchair. Very disorienting.
I'm glad you and your patient are OK.

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Could be worse.  At least you didn't give Vecuronium instead of Versed 🤷‍♂️

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Hey Stephen,

Thanks for sharing your story and remember that you are not alone.  In my ambulatory clinic we follow the patient safety goals of using two identifiers - we ask the person their name and date of birth.  Even though many of our patients have been coming to us for years, it's just another way to ensure we are doing what we need to do - blood draws, medications or whatever.  Don't beat yourself up.  We are all here for you!

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