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Discussion

Med Error

Today during my preceptorship I made a med error. I was giving a patient 5 MG Flexeril. But I accidentally gave her 10 MG. I forgot to cut the pill in half-for some reason I thought the 10 MG pill was 5 MG. My instructor wasn't that mad but was concerned I didn't realize the pill was 10 MG. However, the patient had an order for either 5 MG or 10 MG-we intended to give her 5 MG. Luckily yesterday at the same time she was give 10MG and tolerated it. I just feel so dumb and scared that I'd do suck a thing!!

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    • Featured Replies

    Learn from it- what will you do in the future to prevent it? Many nurses will do something to remember that Pill X needs to be cut in half (aside from just taking a pill cutter with you). Mark the package, keep it separate, whatever works for you, but develop a system for yourself so that you don't forget this in the future. Thankfully this time it wasn't too dangerous, but it may be in the future.

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    • Experts

    You will never forget that again! Luckily, the order was for 5 to 10 mg, so you were technically within the ordered parameters. However, if you intended to give 5 mg, yes, that was indeed an error. Luckily, no harm-no foul in this case. The silver lining in making mistakes is that we learn from them :D

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    • Experts

    Were there parameters on the order? Like give 5mg for x and give 10mg for y?

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    • Author

    No, the order was written 5-10MG

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    • Author

    No, the order was written 5-10MG

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    • Experts

    Technically it's a prescribing error then, dosing is the responsibility of the physician. Deciding when to give 5mg and when to give 10mg is outside of the RN scope of practice. The order should read something like give 5 mg for pain 1-5 and 10 mg for pain 6-10. Unfortunately you'll see it all the time with pain meds.

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    Technically it's a prescribing error then, dosing is the responsibility of the physician. Deciding when to give 5mg and when to give 10mg is outside of the RN scope of practice. The order should read something like give 5 mg for pain 1-5 and 10 mg for pain 6-10. Unfortunately you'll see it all the time with pain meds.

    Absolutely correct.

    CMS & TJC would jump all over a range without parameters.

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