so the other night i made a med error. at our facility the mar is computerized so, we the students before we get on the floor, print all of that information out so we can look stuff up at the hospital pertaining to our patient. the new nurse from some eastern european country i was supposed to be working with was co-working with a more experienced nurse from the unit. we get on the floor at 4:00 so at 4:00 (one or two minuets before) i introduce myself, tell her that i will be doing meds vitals, assessments, all meds that are not iv. i ask her if my patient an 11 month old with a traumatic brain injury if he had gotten his meds yet.
meaning his .5mg of morphine that was due which he is receiving q 3hrs via ng tube.
she said 'no'. only after i passed the med and went to enter it in the computer did i come to discover that she passed the med already (half an hour before i asked and 15 minuets after i printed out the mar) and she thought i was referring to his his 5:00pm med which indeed had not been passed. so because i along with seven other nursing students need our clinical instructor to pass meds with us usually all at the same time, we weren't able to pass it until 5pm (thank god for that). when we go to enter in the computer the he had received his meds it appears that it has already been checked off by someone else an hour and half before that.
i was livid at the nurse but i kept my cool i kept going over in my mind talking/yelling at the nurse who told me that but i never did, my main concern was for my patient. my instructor told me just to monitor him and watch his respirations and hr.
she, my instructor notified the doctor and said it was a communication error because of a language issue.
i know that it is my fault because i am responsible for my patient and i am the one who administered the med. but as a student i want to know what the implications of this are. my instructor just informed me that i need to work with her on a 'clinical learning contract' even though i only have two more clinical days left in the year.
my instructor filled out the incident report while i was watching my patient, (she didn't come back for two more hours because she was busy with other students). i never signed anything, i asked if there was suppose to be something to sign but she said i didn't need to. also she didn't freak out on me and both the new nurse and the more experienced nurse didn't yell at me.
my patient ended up being fine in the end without any problems
Specializes in Day Surgery, Agency, Cath Lab, LTC/Psych.
The Accudose and Pyxis medication administration systems have the last time a med was checked out. It sounds like this situation was beyond your control because you were given misinformation. But, in the future you could check the medication administration system to see when the Morphine was checked out last.
If its any comfort, we all make med errors. This one was not entirely your fault at all.
We have computerized MAR's at our hospital and the floor nurses (and students) take a laptop with them as they give meds which gives them "real-time" info on if a med was given or not. This would have prevented your error.
Be careful with the attitude that it was her fault...sounds like it was a misunderstanding on which med you meant when you asked, not that she gave you "misinformation".
You have received good advice here. The only thing I would add is: in the future, you would be very wise to re-check the computer MAR before you give a dose of anything. The printed MAR is only valid until the minute you printed it, at which point it becomes outdated. You had the misfortune to learn this the hard way, by printing before the other nurse gave the dose, even though you had also spoken with her. I'm so sorry this happened to you as a student. I remember how stressful that time is. But, happily, there was no harmful effects to the patient, and you have learned several important lessons.
You have received good advice here. The only thing I would add is: in the future, you would be very wise to re-check the computer MAR before you give a dose of anything. The printed MAR is only valid until the minute you printed it, at which point it becomes outdated. You had the misfortune to learn this the hard way, by printing before the other nurse gave the dose, even though you had also spoken with her. I'm so sorry this happened to you as a student. I remember how stressful that time is. But, happily, there was no harmful effects to the patient, and you have learned several important lessons.
I agree....I would never rely on a printed MAR if computerized documentation is being used. Paranoia rules....and I always have the screen up to document the med (to see if it's still an 'available allowed dose') on the computer screen and then give it....to be documented immediately....
I've had residents D/C a med in the few mins it takes me to give it and I have no where to document it! I've had to have them give me a "one dose" order to cover the medication....
We all learn from our mistakes...unfortunately it's usually our best lesson:)!
i ask her if my patient an 11 month old with a traumatic brain injury if he had gotten his meds yet.
meaning his .5mg of morphine that was due which he is receiving q 3hrs via ng tube.
she said 'no'. only after i passed the med and went to enter it in the computer did i come to discover that she passed the med already (half an hour before i asked and 15 minuets after i printed out the mar) and she thought i was referring to his his 5:00pm med which indeed had not been passed.
i don't know what will come of this, but i would suggest that in the future you are more specific about which medication you are referring to..you know what they say about those that assume.
Stuff happens. Any nurse who has never made a med error is a nurse who's never had a job.
The biggest lesson you can take away here is that 99.9% of the time people do not make mistakes to be malicious, so give them the benefit of the doubt. The nurse did not do anything to you. She simply answered the question and as it happens, there was a miscommunication. This will happen 1000s of times during your career, and you will be on both ends of that process.
In my nursing program, I would have been kicked out. We had a 0 tolerance med error rule. Since we were the newbies coming in on board, we had to make CERTAIN we giving the right medications and dosages and at the correct times. Bottom line: it was your fault and at my school you would have been kicked out. The good part: yours doesn't really seem to care that much so hooray for you!
In my nursing program, I would have been kicked out. We had a 0 tolerance med error rule. Since we were the newbies coming in on board, we had to make CERTAIN we giving the right medications and dosages and at the correct times. Bottom line: it was your fault and at my school you would have been kicked out. The good part: yours doesn't really seem to care that much so hooray for you!
What an unnecessary post. You seem to get great pleasure in making biting remarks for no reason.
There is no evidence indicating her school "doesn't seem to care that much" so your statement is unwarranted and illogical. Her school is simply handling it in a reasonable manner. It's unfortunate you were never taught how to do the same.
Specializes in Community Health, Med-Surg, Home Health.
I think that the school is being understanding of the fact that mistakes do happen and this can be used as an important lesson to the student. Also, I question schools that really have a 'zero tolerance' to student medication errors. Many times, the response to errors are held behind closed doors, which means anything can happen. What I usually see is that mistakes and disciplinary actions resulted from those errors are not spoken about to the general student body.
I would rather that a school investigate the cause of errors, evaluate the skills and knowledge base of the student and then make a decision rather than make a blanket statement that nothing is tolerated. I do believe, however, that students should not be responsible for administering narcartics to pediatric patients, because the risk is just too great. If that is the case, then, the CI should also take some of the heat, because she should have been right there the entire time.
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cardiacRN2006, ADN, RN
4,106 Posts
Perhaps....but an error is an error.
Students should NOT be giving narcotic meds alone-ESPECIALLY to peds pts!
This was a error on the instructors part as well.