Med error...scared to death now...

[troubled]

It seems that I left a duragesic patch on a pt when changing the patch. No excuse for it happening. This was two days ago.

The kicker is that they sent her for lethargy that had been ongoing for several weeks. The er found the patches, administered narcan and sent her back. The er will report it. I understand that. No issues with it.

My question is what will happen to me?

[totally_nuts]

I may be wrong (it does happen) but my understanding of the patches was that after a certain time they cease to be effective which is why we have to change them so frequently. Having two patches on shouldn't have had a massive effect but what do I know, I'm not a pharmacist.

Acknowledge your mistake to your boss and just go from there. Admitting it is the hardest bit I think.

Good luck!

[tokmom, BSN, RN]

Yep, own it and apologize and tell them you learned a lesson. Then...don't beat yourself up. We have all made mistakes (if you haven't you will, lol) and are still employed. Nobody is perfect. ((hugs!))

[Ms.RN]

Exactly same thing happened at my facility. A patient was admitted to LTC from the hospital. She had a duragesic patch on from the hospital and when LTC nurse who admitted her put a new patch on her. We had to send her back to the hospital. We were reported to the state and had to go through the inservice about med pass, went through survey and passed. A nurse who put new patch on wasnt disciplined. I know its hard but we are all humans and we all make mistakes. I hope your DON can understand about nurses making mistakes.

[JG2010]

Most hospitals no longer have punitive systems in place. They are more intereted in finding learning opportunities when mistakes occur. You are not the first nurse to make a mistake. You may need to report it based on your employers adverse drug reactions or occurrence reporting and it may be great to come up with ideas of how this happened and how to avoid it (for learning opportunity for all your colleagues). There may be a glitch in the system that caused you to make a mistake that may need to be addressed by the higher ups...i.e. too many patients...not checking the sites...etc... Either way, you should be fine. Mistakes happen to all humans. It's gonna be alright.

[bill4745, RN]

Make yourself a rule that you will never put a patch on until you find and remove the previous one, or document why it is not there.

In the ED we frequently get LTC patients for lethargy, low BP, etc. and find 4-5 fentanyl, nitro, etc.

[Meriwhen, ASN, BSN, MSN, RN]

Make yourself a rule that you will never put a patch on until you find and remove the previous one, or document why it is not there.

In the ED we frequently get LTC patients for lethargy, low BP, etc. and find 4-5 fentanyl, nitro, etc.

And be sure to check the patient thoroughly for the patches--we've had more than a few patients put patches on in places that you'd never think to look for them...use your imagination :)

As far as what will happen to you...I don't know. I'm optimistic though: the patient turned out to be fine so that's good--I doubt you'll be fired for it...besides, if they fired every nurse who made a mistake there'd be damn few nurses working.

The best thing you can do is talk to your supervisor, take responsibility for your mistake and learn from it, and go from there. Good luck.

[diane227, LPN, RN]

Speak up, report your own error to your manager and let go, learning to look for the old patch the next time. This happens to people. But it won't happen to you ever again because you have already had the experience and you will be extra cautious in the future.

[clemmm78, RN]

Do you have a system where you can write down where the patch is? I can't get over some of the odd places I've found patches. Sometimes I wonder what the heck the nurse was thinking when he or she placed it. I mean really, am I going to look on the back of the shin???

The best solution is to have a system that when you sign off the patch, you write where it is so the next nurse knows where to look to remove it.

Alternately, you have two sign off areas: one for removing the patch and one for applying it. One institution I worked at did that for daily patches although not for q3day patches.

Mistakes happen. At least this one wasn't irreparable and you know now to watch for this.

[troubled]

They took me off the schedule. I think I'll be looking for a new job. Since I already admitted it, what the heck would they be investigating?

She was alert and oriented the night before. She was in her chair in the lobby talking to me. I bought her a pepsi for cripes sake. She drank it and went to bed.

[netglow, ASN, RN]

:kiss

[brownbook]

Not sure where you are now with this story. EVERYONE has made and will make mistakes. When you become aware one was made you make sure the patient is ok. If the patient is ok notify the supervisor and complete an incident report. An incident report IS NOT punishment. It is an investigative tool to find out what caused the incident and what steps need to be taken to prevent it from happening again. If you're fired that is so wrong, only makes your co-workers more apprehensive about their own job and they'll want to lie and hide any mistakes they make (and they will make mistakes)!