Med error stories

[gemini81sg]

One night at work one of my fellow co-workers, a somewhat new nurse to the unit, approached me stating that she couldn't understand why Dr. so and so was so rude to her on the phone when he was calling in to check on a patient. I asked what happened. This nurse explained to me that she gave 5 mg of Coumadin to a patient admitted with a diagnosis of GI bleed, positive hemoccult stools, a hemoglobin of 8 and an INR of 3.4. Luckily the patient received a transfusion shortly thereafter and the INR came down.

Strangely enough, the same physician had just recently continued this patient's home coumadin on admission just hours before and pharmacy entered the order regardless of the admitting diagnosis.

[edmia, BSN, RN]

Ok, but now for a mistake story:

Once I went to the bedside with all the meds ready from the med room. Everything was either IV or PO and already crushed to go down the ngt. Except for nexium 40 mg ivp, which I had drawn up into a 3 ml flush. This was not labeled so it looked like a flush.

Ok, here comes the moment of absolute panic: I turn to pick up my nexium from the bedside table and realize it is empty. The plunged syringe is there and so is the respiratory guy who has just used it to flush my patient's trach.

The next 10 hours were horrible. My patient's lungs did not seem to suffer any effect as I guess most of those 3 mls were suctioned out, but still, I almost fainted.

I label everything now even if only for the short walk from med room to bedside.

[msn10]

Thanks for all the posts and honesty. Nurses need to learn that mistakes are going to happen and we need to be aware of WHY they happen, not just the error itself.

I teach a nurse residency class for 3 hospital systems. I am going to use some of these stories as "real life" situations, especially the new nurse stories. The nurses connect much better with the stories when they know it can happen to anybody.

[PediLove2147, BSN, RN]

I am glad I found this thread because I need to get this off my chest.

Today I made my second med error in 8 months I had a patient that was anxious so I grabbed 0.5mg of Ativan and was going to give it to her when the doctor called and said she just ordered 5mg Oxycodone for my other patient with a pretty bad HA. I usually never keep more than one patient's meds on my computer but I figured I could quickly give the Oxycodone and then make the trek to my more complicated patient after. I scanned the med, was about to give it when the fall alarm went off. My patient next door (the one that needed Ativan) was very impulsive and since I didn't hear anyone going to her room I left and went to get her. She was up and moving, very unsteady. She could have fallen. Anways, I go back and grab the package and give my patient her med. She got the Ativan, not the Oxycodone! As soon as I realized my mistake my heart started to race and I felt terrible.

I tell the charge nurse I made a mistake and she asks what kind, when I tell her she says, "Oh that's bad." Patient ended up being fine, just a little sleepy with just increased monitoring. I went to the BR and cried. I will never carry more than one patient's meds again that is for sure but I am so nervous because it is my second error. My educator said that after a second error you get a verbal warning, if it happens again, a written warning, again termination so I am not worried about my job but I do feel like a terrible nurse. I need to stop rushing, and slow down. I just hope I can forgive myself.