Med Error

[Daisie4100]

I am super stressed out. I am a triage nurse at a small clinic. I was the part time evening nurse and there was a full time day nurse. I have only worked there for less than 3 months. Yesterday, they fired the daytime triage nurse and asked me if I would take her position. I accepted this morning and then my day went down the tubes. I had multiple calls about possible stroke, heart attack, and fall injuries. Then I had 5 patients come in for shots. All of this between 8 and 10 am.

One of the patients was in for an allergy shot. These shots come with specific instructions from the allergy clinic on dosing. When reading the dosing, I made an error and instead of .10 mL I gave 1.0 mL. I realized my mistake right after. I monitored the patient for 30 minutes, spoke with my manager, called the allergy clinic and spoke with the nurse there. The nurse at the allergy clinic said to have the patient take an antihistamine and monitor for allergic reaction. My manager said to document everything thoroughly and if the patient was fine send him home with instructions. I had to explain to the patient my mistake and gave him the instructions of what to watch for and what to do if there was a reaction. The patient was understandably upset but remained calm. After 30 minutes, there was only a 10-12mm wheal in the area where the shot was administered. The patient felt fine so he went on his way.

I did what I could do in the situation and documented everything. I owned up to my mistake right away. I still feel like I could puke at any second. I feel terrible. This is my first med error and I am thankful that it wasn't tragic. But I just feel like an idiot. Am I being too hard on myself?

[OrganizedChaos, LVN]

Everyone makes mistakes, no one is perfect. I remember when I was working at a jail I took a medicine order over the walkie-talkie. I misunderstood what the RN said & gave the inmate the wrong dose.

I monitored him,!he was fine & we never took orders over the walkie-talkies again!

As long as you did everything you were suppose to do, you are fine. It sounds like you were super busy. Mistakes will happen, as long as you own up to it & learn from it that's all that matters.

[LakeEmerald]

You made a mistake. You were honest. You took appropriate action afterward to ensure your patient's safety. You operated with integrity. That says a lot about the kind of nurse you want to be. It was a learning experience and no one was hurt. It's OK. Just slow down a bit. You can only do one thing at a time.

[dudette10, MSN, RN]

You did everything you were supposed to do. You need to sleep on it, and you'll wake up feeling better, so that you can more calmly reflect on it and learn from it.

[Here.I.Stand, BSN, RN]

Hugs!! We've all made med errors. And I'm guessing allergy shots aren't something that you give every day. I tried to do the shot thing when I was a teenager, and remember the dose wasn't the same every time; they'd try to increase it every so often. Several times I had an anaphylactic reaction and had to come back down on the dose... my point is, I can see how it would be easy to make a dosage error with something like that. Fortunately, he didn't react to the dose he was given.

Does your facility follow the rec's for trailing and leading 0's when transcribing? Like 0.1 instead of .1, and 1 instead of 1.0? If not, that's a systems issue and med errors by a factor of 10 waiting to happen.

I agree with the PPs that you did what you were supposed to following the error, and the pt was fine. Dust yourself off, vow to learn from this, and forgive yourself.

[iluvivt, BSN, RN]

Once you discovered your error you made all the right moves. Now you need to analyze why you made the error. It is just like when you get a paper back that you worked really hard on and looking it over to figure out why points were deducted albeit this is more important!

it sounds like you were distracted because it was chaotic.It will be chaotic again though and what will prevent you from making a similar error? What is it that you need to next time that you did not do this time. Does a process need to change? Do you need to learn some self calming strategies? Do you need to perform a double check after you draw it up and before you administer it. What is it?

[T-Bird78]

I work in an allergy clinic and have done this myself on one of our own pts! The previous dose was .05 and I read it as 0.5 so I administered 0.5 (which is the top dose on allergy shots 98% of the time, rarely will more than 0.5 ml be given). Another nurse realized the error when pt was c/o itching and a cough. When the other nurse showed me the shot record and asked if that was the dose I gave, I immediately realized what I had done. Pt was fine after a neb tx and shot of epi and it made me double check (and double check again) the dose and decimal placement! We now have an electronic record so it's not as easy to skip several doses like that, but I can relate completely with your situation. You're fine. Breathe.

[Been there,done that, ASN, RN]

You have been thrown under the bus. You accepted a "position" with NO training.

Ask yourself why the previous nurse was canned and why you are now in this position.

You were placed in a role you are not trained for . Write this up.. contact your BON regarding this issue.

[nurse lala, BSN, RN]

Honey, you did everything right after discovering your error. It is horrifying to discover our own errors. And I think all good nurses feel panic. The panic passes when you come up with a plan to avoid your error, accept your humanity, and decide to let go.