MED ERROR....

[Jerseygirl314]

First month off orientation and made med error. Gave pt. Same med twice. We use scanners and pt was scheduled for meds almost every hour but nurses combined them and gave them twice a shift instead of all shift long. this was my first time having this pt and Somehow I got mixed up with the early/late scanner override aspect and she got it twice. It was a drug I never heard of. Pt is fine. No adverse effect. I am devastated! I will be written up and will have to speak to 2 managers. Since i am so new I don't know if I will get fired? The entire unit knows.about it also. EVERYBODY....nurses, techs, case workers, MD,.... Not only am I the newbie, but now I am deemed incompetent in a lot of eyes also. They called me at home to.ask.me.about it. I feel absolutely sick! I want to just resign..... thank god.the pt is fine and is not the lawsuit type. I am seriously.thinking of finding another.line of work. I have been a nurse for many years.but this is my first hospital job. What else can I do with a RN degree? (Associates). Uuugh...I feel sick. I want to crawl in a hole...

[jdruds]

Mistakes are human. Unfortunately, being on top of medications is critical to patient safety. What was the medication and dose? Instead of crawling in a hole and jumping ship, reevaluate why the error was made? Were you distracted? Do you practice using the 5 rights with each patient? Also, if you didn't know the medication you were giving, looking it up is crucial. You have to be educating your patients about reason they are taking and any side effects. There are countless entries on here about nurses leaving the profession because of a mistake. Own up to it, learn from it. The feeling you have right now will stick with you and make you a better nurse who is tuned in to medication administration. Sounds like learning the hard way. Good luck!

[ED Nurse, RN]

If a med is to be given at a certain time, and you are able to give it at that time, why deviate from that? I really am not sure what was trying to be accomplished here by all the other nurses. Also, you should NEVER give a medication without knowing what it does. Never do what's convenient, but what's right.

[Jerseygirl314]

Yes. I did look up the drug. The pt was scheduled for meds almost every hour all shift. The drug was one that could have been given more than once. The pt. Said she gets her meds at 5 and 8 every day. I asked the other nurses and they said this was true. So for both med passes there would be early and late overrides. At 5 she got her 4-4:30-5-6pm meds and at 8 she got her 7-8-9-10pm meds. Why the times were not changed is beyond me. Our unit is such that pt request trumps the timing due to pt.rights. no I do not like this system but it is what it is. Even with this confusion, I still accept full accountability. I was told to be careful with the timing issue. I have seen the other nurses pre-scan meds, but I will absolutely NOT do that!

[ED Nurse, RN]

Yes. I did look up the drug. The pt was scheduled for meds almost every hour all shift. The drug was one that could have been given more than once. The pt. Said she gets her meds at 5 and 8 every day. I asked the other nurses and they said this was true. So for both med passes there would be early and late overrides. At 5 she got her 4-4:30-5-6pm meds and at 8 she got her 7-8-9-10pm meds. Why the times were not changed is beyond me. Our unit is such that pt request trumps the timing due to pt.rights. no I do not like this system but it is what it is. Even with this confusion, I still accept full accountability. I was told to be careful with the timing issue. I have seen the other nurses pre-scan meds, but I will absolutely NOT do that!

Giving meds outside the allotted window is a medication error and one that can get you into trouble. If the MD won't change the times then you need to give them when ordered- if the pt refuses then the pt refuses and you document it.

[iluvivt, BSN, RN]

By using the overide function you actually eliminated the safety feature of the program. Had you given the meds as prescribed and scanned as ordered,the system would have alerted you that the dose had been given! You were all probably trying to keep your patient satified but it should not be done when the price is eliminating the safeguards that are designed to reduce such errors, no matter what the pt or family wants, or you are left with explaining your error.

[NanaPoo]

Thankfully your patient is okay and this med error will be a great learning experience to keep you on your toes from now on.

We all make mistakes and it doesn't generally end our careers. I can name 2 right offhand that scared me to death, were huge in my eyes, didn't harm the patients (thank heavens) and taught me some fantastic lessons.

You can never be too careful. Slow yourself down during meds on those super hectic days - it will be worth it in the long run. And double check everyone's work that came before you - double check the doctor's order (is he/she ordering a safe dose?), double check the pharmacy's transcription (did they send you the same dose that the doc ordered?), if a nurse before you signed off the doc order on a prior shift, did he/she read the order correctly?, then go through your 6 rights carefully (more than once if necessary).

And, like the above posters said, know your med!

I gave a too large dose of Morphine early in my career because I was in a rush and super distracted. Thankfully my patient had a high tolerance and probably the 1mg the doc had ordered wouldn't have been enough anyway but, still, I was mortified when I realized what I'd done. A few years later I was working in geri-psych and the night shift nurse before me signed off on orders that clearly said Coumadin 10 mg po. It went to the pharmacist who read it the same way, sent the med to the floor for me to give in the a.m. I checked the order and also read it that way and proceeded to give the med. I was pulled off the floor later that morning and told that it was to have been 1 mg, not 10 mg! Again, absolutely horrified and I received the blame because I was the one who administered the med. My responsibility should have been to go back and see what this patient's prior doses had been and what his labs had been. I was brand spanking new to the floor and walking on to a busy unit but that was no excuse not to check those 2 things prior to medicating. These mistakes were years ago in a land far away but have stuck with me forever as learning experiences.

Amazingly, that patient had no ill effects from the improper dose but I learned A LOT from those errors. It's ultra important to check your patient labs in the morning prior to medicating as well as vitals.

[Maria425]

Reading these replies makes me sad. I've been a nurse for 6 years. I never treat new nurses poorly for making a med error. I've made 3 that I know of in my career. I'm still an excellent nurse and feel no need to shame other less experienced nurses for my own fear-based ego. The lesson is LEARN. If it was a pill then that's one thing. IV meds are more serious. The more direct the route to effectiveness the more caution you should feel in your heart when giving something. Do not let any other nurse shame you or make you feel bad. Probability laws alone predict nearly every nurse will eventually make an error in their career. Just remember this incident and let it further encourage you to BE CAREFUL. Blessings to the OP.