Med error

Ben_Dover · Jun 13, 2017

Where was your second verifier prior to starting your heparin and/or are you in the U.S?

allnurses Guide · Jun 13, 2017

Ok, so first things first. Yes you made a mistake (A big one) but the good news is no harm came to the patient so wipe your eyes, take a deep breath, learn from this and carry on. If you ever meet a nurse who claims to have never made a medication error know that they are lying. It happens to all of us. Accept whatever consequences result from this and again I say move on. Most medication errors happen due to a systems breakdown and not because of any deficiency on the part of the nurse who made the mistake.

You will get through this and be a better nurse for it.

Hppy

NurseD0816 · Jun 13, 2017

Yes, in the US. The order was not in the computer yet, so that is the first place it went wrong. The nurses do it all the time at my facility and I started to do the same... Also, meds can't be barcode scanned in the ER because the aren't verified by pharmacy yet. So, I hung the med, with the incorrect rate and checked it off the MAR after it had been infused. All bad. I will be meeting with my DON to discuss all of this, and hopefully make changes for the better.

Career Columnist / Author · Jun 13, 2017

So... I made my first med error today... a big one. I am new to nursing, been a nurse for a little under 10 months. I was asked to come in and cover 4 hours today for a sick co-worker. I walked in to a patient in the ED complaining of chest pain. My coworkers had started the ER and I jumped in to help right away; I took over the ER after getting report for my other nurses and waited for further orders from my provider. Long story short, I was ordered to hang a heparin infusion (which I have done before) and give an initial bolus of 4000 units... I calculated the concentration which came out to be 25,000 units/ 250 ml D5W. I called my provider to check the rate to be hung and was ordered to give 12 units/ kg which in the this patient would be 1146 units. I did the math while on the phone and double checked with the provider. I got up, walked into the ER and hung that bag.... at 1146.....1146 mls..not units. I poured that bag of heparin into my patient...
I realized my mistake shortly after when I was looking the MAR to prepare my report for the receiving facility.... My stomach just dropped... As soon as I saw the ordered rate I just about puked... I can't believe I did that...
I picked up the phone, called my provider and owned up to what I had done...Trying everything in my power to not burst into tears on the phone. Mean while, I am looking at my patient, scanning for any signs of my mistake. Vitals are good, BP still elevated, but not any higher than initially.
My provider handled it better than I would have if I were him. He called the cardiologist for orders - I was told to just monitor for signs of bleeding. The patient remained completely stable while in the ER and was transferred without problem. I followed up with my provider after the incident and discussed my areas of improvement.
The thing that upsets me the most is that I have literally no excuses! I was not tired, or side-tracked. I was not any busier than any other day, in fact it was a pretty mild ER considering. I had staff members available to help me, and I had even double checked my order with the provider! This was not a new task, I had mixed and calculated heparin drips before. I was not overwhelmed or having a bad day... I just simply made a mistake...
I have been crying for hours now... I know the patient is ok, and I am thankful. But Lord, I do not want this one mistake to ruin my career. Any advice from some seasoned nurses?

I'm so sorry for your experience, and so glad the patient is fine. Heparin has a short half-life and is reversible.

This is all the more reason for smart infusion pumps that help prevent such errors.

When you meet with the DON, tell her what you learned and what steps you plan to take to prevent future med errors.

Then you have to forgive yourself and move forward. Best wishes

Ben_Dover · Jun 13, 2017

Ok, so first things first. Yes you made a mistake (A big one) but the good news is no harm came to the patient so wipe your eyes, take a deep breath, learn from this and carry on. If you ever meet a nurse who claims to have never made a medication error know that they are lying. It happens to all of us. Accept whatever consequences result from this and again I say move on. Most medication errors happen due to a systems breakdown and not because of any deficiency on the part of the nurse who made the mistake.
You will get through this and be a better nurse for it.
Hppy

Yes, in the US. The order 1. was not in the computer yet, so that is the first place it went wrong. The 2. nurses do it all the time at my facility and 3. I started to do the same... Also, meds can't be barcode scanned in the ER because the 4. aren't verified by pharmacy yet. So, I hung the med, with the 5. incorrect rate and checked it off the MAR after it had been infused. All bad. I will be meeting with my DON to discuss all of this, and hopefully make changes for the better.

Hppygr8ful

The OP DID Screw-up, with a BANG. :wacky:

But there are some errors that could have been "EASILY" prevented. The OP, as he or she writes, knew their was a system in place yet did not follow. So it's crystal clear that this error was not based on "systems breaking down." It's the USERS Fault. :woot:

It seems like you learned your lesson. But please always practice common sense and I'm saying that in a most friendly way tone of voice. :inlove:

By the way, while meeting with your DON, you may want to discuss your salary increase, like you are the BOSS :yes:

NurseD0816 · Jun 14, 2017

Thank you for the advice all. I spoke with my DON today and things changing for the better. Thank you again.

Irish_Mist, BSN, RN · Jun 14, 2017

At my hospital, there has to be a second nurse present to verify a heparin drip. Even if that isn't your policy, ask another colleague to verify with you. If you are ever unsure of a med dosage calculation, ask another nurse to look at it.

Yes, you made a rather huge med error. YOU ARE HUMAN. Mistakes are going to happen. Fortunately, the patient is okay and there is an antidote to heparin. Bet you won't make this mistake again. Follow your rights of medication, ask a colleague to verify if ever unsure, and you should be good to go.

chare · Jun 14, 2017

Thank you for the advice all. I spoke with my DON today and thingjs changing for the better. Thank you again.

What changes came out of the meeting?

And, more importantly, what changes are you going to make in your practice?

K9lover, ASN, RN · Jun 14, 2017

I hope you can stop beating yourself up, we have all made mistakes and this one will not only not ruin your career you will be better for it in the long run. Sometimes I think we go over things more when we know we are tired and/or it is very busy, you learned from of and the patient was not harmed.

bevtag · Jun 14, 2017

Forgive yourself, learn from your mistake and move on.

jemag41 · Jun 14, 2017

May I ask what type of pump you were using? Because the pump I am used to only goes up to 999 mL/hour. Also, you should report this to the Institute for Safe Medication Practices (ISMP). It is completely confidential and non-punitive. You don't even need to leave your name but it helps if you do because they like to communicate with you if they have questions. This organizations studies medication errors and the "reporting" is not to get anyone in trouble but rather other people learning from mistakes in order to prevent future similar errors. Please consider! Report Medication Error To ISMP