Med error question


Today was a rare day in my ED, we had an extra nurse. I was chosen to float. We do this when we can. The float nurse will help start IVs, pass meds and dc patients. Night was going fine. I look at my board and a dc pops up with an order of toradol IM and zofran SL. Since we have a policy of a 30 minute watch time after injections I figured I would knock out the meds for the nurse and get her dc paperwork ready during her watch time.

So I draw up the 60 mg of toradol and head to the patient's room. I pull up the MAR and I see an hour before she had been given dilauded IM. I ask if she was still in pain (she came in for back pain) and she was. I see she is allergic to mobic so I ask her what her allergy is (said her stomach bled) and I ask her if she had had toradol before (she had). Well our system will flag an allergy so I knew when they order was put in for the toradol, it had to be over-rided. So I scan her bracelet, the med, give her the injection and leave the room to go get her paperwork ready.

That's when it happens. I run into her nurse and let her know I gave the meds and I was getting her paperwork ready. She is upset. Well turns out she had put the order in on the wrong patient. She was trying to cancel the order as I was walking out of the patient's room. I felt like I was going to pass out.

We go straight to the NP that was in assigned to the patient. Confirmed with the patient her "allergy" to mobic and we watched her for any reaction (there was none). We informed the charge nurse and wrote the incident report.

My charge nurse was really good about it. He talked to me about his med error (I think to make me feel better, ha!) I am truly mortified though. I know I share equal blame in this because I could have always asked her before I went in to do it. I feel terrible that I could have hurt the patient and that I probably got my coworker in a lot of trouble with me. I feel like I won't (and maybe rightfully so) be trusted by my peers. At the end of the shift my coworker was really nice about it, but I still feel terrible. I know I've seen posts about med errors before, but I'm looking to see if anyone has had one similar to mine and can share how they got past it. Thanks in advance!

Specializes in Emergency. Has 21 years experience.

Errors happen. No harm to pt so don't beat yourself up.

Specializes in critical care, ER,ICU, CVSURG, CCU.

I agree with embt, the only thing I might have done different, would possibly tell the assigned nurse, you were wanted to give the melds, faciliting watch period, and discharge flow.....bless you for being so helpful, and apparently positive attitude, some that float, are not.....

shake it off, don't beat yourself up....I would work with you any day :D


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Specializes in Medical-Surgical/Float Pool/Stepdown. Has 6+ years experience.

Agree with the above posters, other than running it by prior to the primary nurse (which would have been the best thing probably but maybe not if it was the MD wanting to make changes) you had a valid order in the Pt's MAR.

Specializes in Emergency, Trauma, Critical Care. Has 14 years experience.

Ive had a similar thing happen in the past. I usually try to notify the nurse. None of the meds you were giving this pt were unreasonable assumptions and the doc had put those orders under the pts name. The reason I always run meds by the primary RN now is because they know the pt better. I had a coworker go to give 80 mg of lasix on a pt for me and I'm so glad she ran it by me because I said hold off because I needed to verify with the doc because the pt had no history of CHF and we hadn't drawn a BNP and his X-ray had looked ok. She went and ran it by the doc for me, sure enough wrong pt! That was obviously a much different scenario. The meds did not make sense for the patient in that case.

I think most prudent nurses would investigate, but in a hurry I can see errors getting made. Don't beat yourself up, this has happened many times in an ER and Short of questioning the doc regarding reasonable orders every time....I'm not sure how it can be prevented. I just wish they paid more attention to who they put the orders under.