med error and Sick about it

[hello2you]

after 14 years in the same area of nursing with certification and all I decided i wanted to branch out- check out another interest. I have felt like a "newbie" for sure but this is the challange i wanted

HOWEVER

I have made a medication error! I cannot believe it i have NEVER made an med error, I keep beating myself up about it and now i even wonder if it will be reported to the state board

I have absolutley no excuse all i can think is WHAT THE HECK WAS I THINKING!

i keep trying to rationalize and all i can think is maybe I am trying to force myself in this new envirnment but it really really is distracting..(psych) wayyyy different, i think i should give notice

i took an order that the physicain kep changing but i repeated it several times and at hte end of the conversation she agreed with what i "read back" then i administered a different med... WTH?!?!?!?!? order was for clonidine i gave klonopin

AND i put the wrong time by not using military time ( i am used to working day and this was swing)

when the supervisor called me in i was dumbfounded/embarrassed/ashamed I just couldn't believe it! he reminded me of the 5 rights---OMG! this is what i impress upon students

WHAT THE HECK IS WRONG WITH ME! they must think I am so lame and thank goodness the person is ok I always thought i was cautious but now i am soooo gun shy.

i really don't know these new meds well enough to know if i should be "calling" the physician on the order so that makes me feel vulnerable and i usually run it by someone else

I cant believe I gave someone the wrong medication

I got a verbal warning and signed a paper, i had the oppertunity to put a reason... i don't have one

Do you think my license will get revoked or suspended? I don't have an excuse

it doesnt even matter that it is my only med error in 14years- it is an error -period

[tewdles, RN]

ativan/advil

I love the generics for opioids...patients must discern the difference between morphine ES and IR...etc.

[sethmctenn]

so what you are saying is that you have a 0.0000001% rate of error for medication administration or some other ridiculously low percentage. It sounds like you do a great job. You made an error but I would be willing to bet that this one error that caused no harm will be enough reminder that you are careful to the extreme for the rest of your career.

[ginaweena69]

We are only human. Rest assured you won't make the same mistake again. Life is a learning experience and if we never make changes in order to maintain comfortability then we never grow, as people, or nurses. Hats off to you for venturing out of your comfort zone, and being accountable and honest. If we never fail, then we can't experience success.

[kcochrane]

No harm came to the patient, you feel bad and I bet you learned from this. So don't beat yourself up. Go on from here and remember this in the back of your mind on why the 5 rights exist. I've never know the board to be pulled in for a minor med error without harm to the patient.

[elcue]

I'm so sorry you are dealing with this stress. It happens to so many of us and any nurse who makes a med error suffers internally about it.

I made the same error, in reverse, recently. I, too, was sick at heart even though I knew the patient wasn't harmed. I had an extremely anxious pre-op patient for whom I heard the doc order klonipin, which made perfect sense to me. He'd actually ordered clonidine. I so wish we had a generic names only policy at our hospital. One of my clinical sites when I was in school 29 years ago had such a policy, and it surely helped clarify things.

Try to relax and get your confidence back. You know you are a good nurse. Good luck to you. Linda

[mustlovepoodles, RN]

Awww, you're okay. I"m surprised it took you 14 years to make a mistake! It goes with the territory. Sooner or later, if you give enough drugs you're bound to miss something. There were no serious consequences in this instance, so hike up your dress and march on. This is a mistake you will NEVER make again.:)

I made a terrible mistake about 20 years ago. I had been working in NICU about 6 months and I had to give a premie oral digoxin. I drew up the dose, checked it, did my 5 Rights, and then gave the med. Only after I gave it did the mother say "Gee, that's a lot of medicine! did they change the dose?"

OMG:eek:OMG:eek:OMG:eek:OMG:eek:OMG:eek:OMG:eek:

I went back and looked AGAIN at the MAR and dose said "digoxin 0.4ml". I gave FOUR ML! OMG

Of course, I snatched up the baby and immediately placed an NG tube and withdrew as much as I could, but it wasn't quick enough. I was so distraught my charge nurse had to call the doctor and get new orders. They had to send me home for the rest of the day because I couldn't stop crying.THankfully, the mother nor the doctor was terribly upset. I was sure I had killed the baby, but she just had a little bit of a low heart rate for a few hours and then she was fine.

It was an eye-opening lesson, one I have never repeated. I check and double check meds and from that day forth while I worked in NICU i had another RN check ALLLLL my meds before I gave them.

[txhorns10]

You'd be horrified at how common med errors are. I was a pharmacy tech in two different hospitals. In one we did manual charges/credits. So, the nurses had access to anything in the PYXIS. We'd get a report the next day with everything nurses pulled for what pt. and then had to charge (it basically ended up that we audited everything the nurses gave or at least pulled). Well, obviously when we didn't have orders we couldn't charge and had to e-mail out and find out what was going on. Sometimes orders hadn't been sent, but sometimes it was a mistake. Most of the time it was something like oxycodone instead of hydrocodone. But we also had lots of other sound alike/look alike mix-ups (hydoxyzine v hydralazine, hydroxyzine hcl vs hydroxyzine pamoate, novolog v novolin, etc, etc). It got to the point where we had to put bright orange stickers on the cubies for these drugs in the pyxis that said sound alike/look alike as a reminder. Actually, according to our director, it's a JCAHO requirement to mark said drugs. At least that hospital was on generic name only. The second hospital I worked at used Omnicell and only allowed nurses to pull meds on the MAR. I kind of hope when I eventually become a nurse, our hospital is like that. Anyway, it's not hard to make a mistake like that. One thing I'd suggest (since you're new to psych and a lot of the sound alikes/look alikes are used there) is to google sound alike/look alikes. Having seen a list of them, it caused me to automatically double check in my mind before I pulled any of them to load/fill. Don't be hard on yourself, you made that mistake once and you'll never make it again.

[sissiesmama, ASN, RN]

Just the fact that you feel so bad about making the error says a lot. When I was in school, one of our instructors talked to us about med errors and said that if someone says that they have never made an error that they are lying. Probably not 100 percent accurate, but SO many errors are made, some not very serious, but some far worse than yours.

Anne, RNC