Med error!

kids · May 22, 2010

This isn't a simple error, it could very well end up being reported.

Meds have to be stored in their original container unless relabeled by a pharmacist. You should NEVER dump one bottle into another for this very reason.

Jules A, MSN · May 22, 2010

She made a bad choice simple as that and I would bet my life she won't ever do this again. No it should not be reported to the BON. I would urge you to reach out to her and offer support because I promise your time will come. Every nurse makes a med error at some point and the ones that swear the haven't are the worst, imo, because they are either too arrogant to admit them or too stupid to recognize them.

lkwashington · May 22, 2010

At the facility I work, we used the patients home meds unless it is a med we dont carry or hard to get. Then we would request the family to bring it in and it would be labeled by the Pharmacist. I agree with KIDS this is not a simple med error. This med error did not require the use of the 5 medication rights at all. If the medication rights were used, what would be the outcome of the patient (stable or unstable). This may not be reported by you but it can be reported by the Pharmacy Tech. This is the PT job if not PT is not doing theirs. Some one should be accountable to make sure it want happen again.

dblpn · May 22, 2010

One of the employees at my facility graduated from the same place as I did. Last week she made a med error. She took a medication that a family member brought in and poured the contents of the bottle into the bottle of the "same" med the resident had in the med cart. a few days later, a med tech on that cart got to looking and realized that the med was the same name but a different strength. So instead of the patient getting two 20 mgs they got two 40mgs. I felt so bad for her but she should have read the bottle the family member brought in. When the schedule came out yesterday she was not on it for the first two weeks. So they must have suspended her. Do you think she should have been fired? When you make a med error like this, is the facility required to report it to the board of nursing?

I doubt they'll report it to the BON, unless something drastic happend to the resident like cardiac arrest or death something like that. We as nurses have to be very vigilent when it comes to meds: check, check, check, and check again. i'm sure this incident will make her more aware of what she's doing when it comes to medications. i hope they won't fire her we all make mistakes and learn from them.

Peds_Nurse · May 23, 2010

I found out yesterday during my shift change that a new RN made a med error. She inadvertently gave a different patient's meds to someone else. The medication was a narcotic and one that both patients take, but the error was that the person ended up with twice the dosage they usually get.

I don't think this error was reported to anyone, it seems as though the nurses (I'm new there) are covering for this new RN as I didn't see any documentation about the error when I received report.

Any advice as to what to do? Should I report it, or just keep quiet like the other nurses are doing? I don't want to be labeled as a whistleblower, but I'm also concerned about my patient's well being, if she thinks she can get away with this, she may not feel she can be disciplined.

Any thoughts?

lkwashington · May 23, 2010

I found out yesterday during my shift change that a new RN made a med error. She inadvertently gave a different patient's meds to someone else. The medication was a narcotic and one that both patients take, but the error was that the person ended up with twice the dosage they usually get.
I don't think this error was reported to anyone, it seems as though the nurses (I'm new there) are covering for this new RN as I didn't see any documentation about the error when I received report.
Any advice as to what to do? Should I report it, or just keep quiet like the other nurses are doing? I don't want to be labeled as a whistleblower, but I'm also concerned about my patient's well being, if she thinks she can get away with this, she may not feel she can be disciplined.
Any thoughts?

I believe an incident report should be done because if there are some special reasons why med errors are done maybe it can be fixed by changing the administering med process. At the facility I work we have something called eMAR electronic medication administration record. We also do shift chart checks with the chart and the eMAR to prevent mistakes. I would ask the nurse manger just some general questions not pointing fingers.

morte, LPN, LVN · May 23, 2010

I found out yesterday during my shift change that a new RN made a med error. She inadvertently gave a different patient's meds to someone else. The medication was a narcotic and one that both patients take, but the error was that the person ended up with twice the dosage they usually get.
I don't think this error was reported to anyone, it seems as though the nurses (I'm new there) are covering for this new RN as I didn't see any documentation about the error when I received report.
Any advice as to what to do? Should I report it, or just keep quiet like the other nurses are doing? I don't want to be labeled as a whistleblower, but I'm also concerned about my patient's well being, if she thinks she can get away with this, she may not feel she can be disciplined.
Any thoughts?

you can not know if a report was done....in fact you dont really "know" that an error was made.....stay out of it.

Meriwhen, ASN, BSN, MSN, RN · May 24, 2010

I don't think this error was reported to anyone, it seems as though the nurses (I'm new there) are covering for this new RN as I didn't see any documentation about the error when I received report.

And you may not see any documentation. If an incident report was filed by the previous shift, it certainly would not be shown to you since you weren't involved in the error. Nor would it be documented in the nursing notes (remember Charting 101) nor would it be placed in the patient's chart. Though there should have been some documentation if there was an error, e.g. "Patient ordered 20mg of omeprazole; patient received 40mg. MD notified. Patient montiored through the evening; no adverse side effects reported."

If you have any concerns, you can show what you found to your charge nurse and take it from there. She may be able to find if there was an incident report filed already; if not one should be filed...and incident reports are meant to help fix problems, not be seen as a punishment. And patient safety has to come first.

Or you may find out that it wasn't a mistake at all--after all, unless you were there, you really don't know what happened.

Peds_Nurse · May 24, 2010

Thank you for all the thoughts and advice. I was on that wing last night and, yes the med error is documented in the patient's chart, stating the MD and RP was notified and the patient is on our 72 hr charting for any adverse reactions to the error.

The nurse in question was suppose to come in to relieve me last night, but she didn't come in, it was a different "on call" nurse that showed up. So, I'm only assuming here, there may have been a suspension.

My facility is very, very sticky on any med error. For myself, I double, even triple check before I give a medication. I know I'll probably be guilty of a med error some time in my career, but if I'm very careful, I'm hoping it's not one that will be serious and injure my patient.

Again, thank you for your advice.