Skip to content
View in the app

A better way to browse. Learn more.
allnurses

A full-screen app on your home screen with push notifications, badges and more.

To install this app on iOS and iPadOS
  1. Tap the Share icon in Safari
  2. Scroll the menu and tap Add to Home Screen.
  3. Tap Add in the top-right corner.
To install this app on Android
  1. Tap the 3-dot menu (⋮) in the top-right corner of the browser.
  2. Tap Add to Home screen or Install app.
  3. Confirm by tapping Install.
Discussion

Med error

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?

  • Quote

    • Featured Replies

    My concern is it didn't trigger a little bug in your brain when you were setting a drip (or any fluid really) for a rate of over 1000ml/hr. Most IV pumps won't even go that high.

    Same if you ever had to open 13 vials of any kind of medication to get the dose you calculate. Most drugs are so packaged that you don't need to open more than 2 or 3. If your calculations work out to some bizarre number, check with another nurse.

    Take mistakes seriously but most important learn what may have caused the mistake in the first place. We all make mistakes but we try to minimize them as we gain experience in how to avoid making them.

    Keep an eye on the big picture.

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

    not all facilities require this. I came from a facility that required a witness to put in their id/pw for many drips such as heparin/fent/etc....

    I actually just moved to a very well known teaching hospital that does NOT require a witness. Yes OP made a mistake and owned up to it and did everything right after noticing the mistake. I can tell they feel horrible about it and learned their lesson. No need to make them feel worse when they probably came here looking for advice.

  • Quote
    • Author

    We now have a written protocol requiring 2 nurses to verify a heparin drip, etc. Not only will I be following this protocol personally, but I will also make sure to double check all orders prior to administration of any med, utilize the bar code system to the best of its ability, and really truly stop following the "crowd". Just because this is the way some nurses practice, does not make it ok. I learned this lesson by making a huge mistake - I am going to look at this as my wake up call - it is my nursing license - I will be practicing in the most prudent manner I possibly can from here on out.

  • Quote
    We now have a written protocol requiring 2 nurses to verify a heparin drip, etc. Not only will I be following this protocol personally, but I will also make sure to double check all orders prior to administration of any med, utilize the bar code system to the best of its ability, and really truly stop following the "crowd". Just because this is the way some nurses practice, does not make it ok. I learned this lesson by making a huge mistake - I am going to look at this as my wake up call - it is my nursing license - I will be practicing in the most prudent manner I possibly can from here on out.
    Bravo.

    One bit of your thinking that could stand to be tweaked:

    I am going to look at this as my wake up call - it is my nursing license - I will be practicing in the most prudent manner I possibly can from here on out.
    IMO, it's not about your license... it's about the patients who have entrusted themselves to your care.
  • Quote
    [...]

    IMO, it's not about your license... it's about the patients who have entrusted themselves to your care.

    So true, and so unfortunate that many seem to forget this.

  • Quote

    We are not God. We are human so we will make mistakes. Don't beat yourself up. You learned a lesson and you can even use this to help new grads!

  • Quote

    • Join the conversation

    You can post now and register later. If you have an account, sign in now to post with your account.

    Guest
    Add a Comment
    Go to topic listing

    Currently Reading 0

    • No registered users viewing this page.

    Account

    Navigation

    Search

    Search

    Configure browser push notifications
    Chrome (Android)
    1. Tap the lock icon next to the address bar.
    2. Tap Permissions → Notifications.
    3. Adjust your preference.
    Chrome (Desktop)
    1. Click the padlock icon in the address bar.
    2. Select Site settings.
    3. Find Notifications and adjust your preference.