Med error

amoLucia · Mar 6, 2021

41 minutes ago, Firts ICU job said:

..... we are all humans ultimately we will make mistakes, whether you're made aware of them or not. We're all human. Just try not to make the same mistakes multiple times.

..... but because if I can’t make mistakes and learn from how I can be successful at my work ? ThBk you

OP - I started reading your post sympathetically, knowing full well that we all are subject to making mistakes. But I have serious concerns about this episode and your response. I am NOT out to bash you

For your super to be sensing bad vibes in only 2 days is worrisome. You're blaming the super for taking the hard line with you. Super could prob have been more tactful. However this error is among the most serious kinds - may be considered a 'sentinel' event and could be reported to the DOH, JCAHO, CMS, and reporting you to your BON. Most likely, there will be a major internal investigation.

It sounds like you're giving yourself and others PERMISSION to make mistakes - as if mistakes are inevitable, so it's OK if they happen!

NO WAY!!! And that may be what your super is sensing. Also, the magnitude of this error REQUIRED your preceptor to report it immed and right to the top.

I don't see any evidence of your taking ownership of the error and your omission of 1 of the '5 rights'. How did you miss the route and how can you prevent it for the future??? I'm not expecting you to flagellate yourself, but I don't see any remorse for your error. Just an 'oh, well'. Not even an 'I'm so sorry'.

I've made some BIG stupid mistakes myself, so I am sensitive to others when they happen. I don't know what you're expecting from this posting. I'm sure others understand how devastating errors can be, personally & professionally. You speak of learning from mistakes and moving on. Not knowing if you've made mistakes in the past, but this your opp'ty for serious introspection.

Also, I hope everything turns out OK for the pt in the long run. There could be a big lawsuit here. You should contact your malpractice insurance carrier immed.

Welcome to AN, even under these most trying circumstances. Good luck to you in your future.

Firts ICu job · Mar 6, 2021

I appreciate your comment but I don’t think you understand what I wrote . I am not saying that what I did was something to take light , or tgat I am not feeling bad for that . I am feeling terrible and many times I said that I was sorry and won’t happen again . I can’t keep punishing myself more . I have learned and I will be extra careful . What you saying is that I don’t care . Is not true . Thank God the patient is fine but the approach could have been differently . I am very sensitive to others as well . You mentioned that you don't see any remorse for my error. Just an 'oh, well'. Not even an 'I'm so sorry'. I am sorry but you are wrong , don’t judge me and don’t make me feel more worse . I didn’t wrote the post for that , this is my fist serious mistake as a nurse and I am not proud about . I am NOT give others permission as you mentioned to others to make mistakes , happens and as yourself mentioned too , you did a lot BIG mistakes and I am sure you are not proud about it . However , thank you for wishing me luck with my situation .

amoLucia · Mar 7, 2021

Like I said, I wasn't intending to bash you. Sometimes it's very hard to explain in depth a serious situation with all its fine nuances. And then it's also dependent on individual reader interpretation. Your post left me wondering.

FWIW, I do think there will be further investigation that may become very bumpy for you. Do you have union representation?

Everybody makes mistakes; all we can do is grow from the experience.

Wishing you well.

neuron · Mar 9, 2021

On 3/6/2021 at 1:51 PM, Firts ICU job said:

I was transfer to ICU from working at med/surg floor for two years . I love critical care and always want ICU . I just started last week , unfortunately my second day I make a terrible mistake on a medication route . I had to give oxycodone liquid through a mouth tube on this Intubated patient and I was with my preceptor . However , I took the med prepared to give in a syringe and then suddenly I changed and gave IV instead . Once I realized was wrong route, preceptor saw it and told me is wrong and I stop Pushing and flush twice , nothing happen , patient was fine but I felt terrible . I don’t know why I did that believe me, I don’t know why I change , I don’t have answer for that even though I am killing myself to find why I did that , what I was thinking . The preceptor told the supervisor which he call me at his office next day .

My perspective is you changed the route with a critical care patient who was vulnerable, controlled drug and you don't see why the nurse went to the supervisor immediately. That is her license, and a patients life, if she had not reported it she could be in trouble. Those are her patients that she/he is responsible for. Another thing is your post is hard to read, lots of grammatical errors that aren't everyday - not sure I could trust someone with so many errors - Not trying to be rude, just sayin'.

ORnurseLovesHerOfficer · Mar 13, 2021

You state you are very sensitive to others, does this mean you are a sensitive person? Or that you are sensitive to other people’s needs? If it was the first one, I wonder if nursing as a career has any sort of longevity for you. Having a thick skin is almost as important as clinical skills I feel. As the other responder stated, you are most certainly in for a bumpy road and I would make sure your malpractice insurance is up to date etc.

I was actually the victim of a critical incident from a medication error. I had just graduated nursing school and was in the hospital myself. I was given a IM medication via IV and suffered bad side affects, not to mention the most horrendous pain I have ever felt when she gave it to me. To make a long story short, this nurse did not apologize to me, she ended up losing her job and her license was suspended pending an investigation. I ended up moving different states after that incident and don’t know what happened to her.
I have been a nurse almost 12 years and the only medication error I made was I gave 50mg of Trazadone instead of 25mg....I don’t care what situation I am in, I triple check everything.
I hope every thing works out for that patient.

londonflo · Mar 17, 2021

On 3/6/2021 at 1:51 PM, Firts ICU job said:

However , I took the med prepared to give in a syringe and then suddenly I changed and gave IV instead . Once I realized was wrong route, preceptor saw it and told me is wrong and I stop Pushing and flush twice , nothing happen , patient was fine but I felt terrible . I don’t know why I did that believe me,

None of us make an error intentionally. I wonder what distracted you because any liquid oral medication does NOT have the same look as an IV medication. The fact of the matter is, if your preceptor wasn't there you may have introduced a viscous solution into your patients blood stream. If you truly want to learn safe practice I would suggest you talk to the hospital about any remediation educational programs available.

On 3/6/2021 at 1:51 PM, Firts ICU job said:

That was so discourage and detrimental for me tgat I don’t want go back there anymore . I know was bad and stupid but he could use another approach with me

Frankly, there was no good approach for a preceptor in this situation. He had to stop your actions which could have been very harmful. Stop thinking about how this incident effected you. Think about a vulnerable patient. It is always best to stop, review the medication and it's route when you identify the patient.

Best wishes for your future practice but stop thinking about how your neglect of the proper route effected you. Think more about how/why this happened and look for some strategies to learn a more focused medication administration.

Best wishes to you,, Your career will survive if you own the onus and show a willingness to learn.

Nurse Pompom · Apr 23, 2021

Hello,

I read your post last night and I was still thinking about you this morning so I thought I should answer your post.

First let me tell you that I'm sorry that this happened to you, your patient, and anybody else involved. A medication error is such a serious event. I can imagine how distressed you felt.

I work in ICU and I know how stressful it can be. Nurses with experience are considered new nurses when they start in ICU. They aren't considered new grads, but they still go through a few months of training, and there is a reason for that; ICU is a challenging world and you have to change the way you do nursing.

Being new in ICU we sometimes feel like a deer in the headlights. You are still responsible for the mistake but, really, your preceptor also has to share the blame since you're the "preceptee". She/he was right to report it right away. If you ever make a mistake, you should report it right away yourself too. In my hospital we are encouraged to report such mistakes and the team works together to find a way for the mistake not to happen again.

Now I thought about you as I said. You stated that..

On 3/6/2021 at 2:51 PM, Firts ICU job said:

I had to give oxycodone liquid through a mouth tube on this Intubated patient and I was with my preceptor . However , I took the med prepared to give in a syringe and then suddenly I changed and gave IV instead

From what I understand, you had to give PO Oxicodone through a orogastric tube. The medication had been drawn in a regular syringe. If I got this right (please tell me if I am wrong), I would want to know why it was in a regular "blunt" style syringe and not an enteral syringe. The enteral syringe can't be locked into an IV hub like a regular syringe. I think that is why the mistake happened.

On 3/6/2021 at 2:51 PM, Firts ICU job said:

he said I don’t care I still have a bad VIBE with you and what you did and I don’t think you will be good here

Yeah well, I had a bad vibe about one of the doctors on my floor when I first met him, I now love him to death. Everybody makes mistakes. I'm not saying it's OK, and I'm not saying we should keep making them, but in decades of nursing or medical practice, mistakes are bound to happen.

To me it's unprofessional to tell your employee "I have a bad vibe about you". What is this? Also, you should never have such a meeting without your union present.

On 3/13/2021 at 1:40 PM, ORnurseLovesHerOfficer said:

I have been a nurse almost 12 years and the only medication error I made was I gave 50mg of Trazadone instead of 25mg....I don’t care what situation I am in, I triple check everything

You got lucky. This 50mg Trazadone could have been another medication and your patient could be dead. Please don't judge other people. You clearly have made mistakes too. That's probably why you now triple check everything.

On 3/9/2021 at 5:57 PM, fibroblast said:

Another thing is your post is hard to read, lots of grammatical errors that aren't everyday - not sure I could trust someone with so many errors - Not trying to be rude, just sayin'.

So.. not all people on this forum speak English as their primary language. We don't know where this nurse is from. I don't judge people by the way they master the English grammar or by their accent, if they have one.

All in all you have to be accountable for your mistakes. Work harder, ask about the policies in place in your hospital, no matter what, don't cut corners because other people are getting away with it.

I know you feel terrible. Maybe ICU isn't for you or maybe it was the one mistake of an entire ICU career. I do hope you learned from it and that it will make you a great nurse.

neuron · Apr 23, 2021

3 minutes ago, Nurse Pompom said:

So.. not all people on this forum speak English as their primary language. We don't know where this nurse is from. I don't judge people by the way they master the English grammar or by their accent, if they have one.

who's judging? It's my observation and I based that on the grammar + med error. You can't conveniently make errors on the ICU.

Nurse Pompom · Apr 23, 2021

Grammar has nothing to do with what happened. You don't know where this person is from and where he/she works. No one makes mistakes on purpose, "conveniently", in the ICU or anywhere else.

For people to come forward we have to accept a mistake has been made and instead of placing judgement, understand why the mistake happened in the first place. Was it negligence, was it a pharmacy error, was it in the way the order was written, were you understaffed, were you teaching someone else and got distracted, etc..

When people don't feel like they can safely report their mistakes, they don't report them at all. Medications errors are at the top of the list when it comes to mistakes nurses make.

Does it make it "okay"? Of course not. Nothing is being excused, but the key solution doesn't lay in blaming that person but in the prevention of future mistakes.

TriciaJ, RN · Apr 28, 2021

I agree with londonflo. The only thing to feel bad about is the harm that could have happened to a vulnerable patient.

Even if your supervisor spoke unprofessionally, it shouldn't have the power to make you feel any worse than you already do, so it's moot. Your preceptor and your supervisor are also likely to take the heat for your error, so it might have been unrealistic to expect "a different approach".

At this point, you can prove your supervisor right or wrong. Make it your goal in life to never make another mistake and take full ownership of any error you do make. Show the supervisor that you take the patient experience very seriously and you take errors seriously.

Any new position requires us to earn the trust of others. An early error can set that back a bit. Now it's up to you to put it right.

NrsGuy · Apr 26

I know this is an old but still want to comment for any younger nurses reading this. At first my thought was why is your preceptor allowing you to give medications on your first week? You should be shadowing for at least 3 shifts. But then I remembered you're an experienced nurse with two years med surg experience. The medication you gave was NOT a critical care medication. Patients receive meds via OGT routinely in med surg. The fact that you drew this medication in an IV syringe rather than a toomey syringe tells me you don't have the basic nursing skills that a med surg nurse with two years experience would have. That said, that does not mean you cannot be a good ICU nurse - it just means you need to do an inventory of your skill set - go on Google and search "nursing skills checklists,” and brush up on your skills. If you haven't done something before, or if it's been a while since you've done it, ASK first. I have over 10 years experience as a nurse, 5 of them in critical care, and sometimes when I'm doing something risky, I still ask a more senior nurse to come and watch me or standby why I do it to ensure I have backup in case something goes wrong. HUMILITY will go a long way but also understanding that peoples lives are at risk is crucial here. From my standpoint, the blame falls on you, the preceptor, and the nurse manager equally. You didn't verify the 5 rights, it was your second day on the unit so your preceptor should have been watching you like a hawk even before you drew the medication, so he didn't verify the 5 rights either, and the nurse manager failed to assess your nursing skills and understand where there might be gaps and how they can help you fill in those gaps. I'd love an update to see what happened but hopefully, they gave you a two week observational period where you're learning nursing and ICU skills and validating your competency before allowing you to continue and I also hope they didn't just term you and/or you didn't quit/transfer back to your unit. The most important thing about med errors is to acknowledge them, understand why they happened, and our systems in place to make sure it never happens again - at the end of the day, if one nurse made the error, it's likely that another nurse can make that same error.