2 Med Errors. Feeling soo incompetent : /

[RN4116]

Hi Allnurses! I need some advice. I've been at my Place of work for about 5 mos, I've made 2 med errors and feel so awful about it. My first error was when I first started night shift, we were understaffed, it was soo busy and a patient had come up from surgery. When I first came on the unit, there were no meds listed for this patient. Once the patient was transferred to our floor, nothing was said In report whether something was due etc etc. The doc came to see the patient and gave me specific instructions. When I went to do my 24hr order checks at 4am, I saw I missed a 1x dose antibiotic and a decadron!!!! There was also an upcoming decadron dose due at 6am. I freaked out and called my supervisor. In the end all I needed to do was fill out an incident report. No harm ever came to the patient. My second error was 2 mg of Xanax was ordered for my patient. I don't know how I missed that we only had 0.25mg in stock and I only gave her 1 pill instead of 8 which would equal the 2mg!!. Thats patient was discharged that very same day, no harm done. I didnt even realize i had comitted an error until one of my senior nurses caught the error. She told me it was alright and was clearly a rookie mistake. She never reported the error. 1 week later I receive a phone call from my nurse manager asking me about the error. She was soo annoyed and I felt so horrible. I feel as if my nurse manager is so disappointed in me. When I first started she seemed very pleased with me. Now I think otherwise. I feel so incompetent and am having a very difficult time getting over this. Am I a horrible nurse?? Any input would be greatly appreciated. Thank you.

[Been there,done that, ASN, RN]

It is easy to miss a dose in the first 8 hours. The MAR has not been printed, everything is off schedule.. and I have many, many times just marked the some first post-op meds as not given,, because pharmacy scheduled it incorrectly and the schedule itself is just starting.

I 've been a nurse for 30 years... there are STILL times I glance at the med and see the stocked dose , as the ordered dose. I feel that is an error in any MAR program to show the stocked dose, and should just show the ordered dose.

It's up to the nurse to make the dose accurate anyway!

"I feel as if my nurse manager is so disappointed in me. When I first started she seemed very pleased with me. Now I think otherwise. " I think you're reading WAAAY to much into her . She no doubt has other things on her mind.

You are human and you are doing fine!

[RN4116]

Thanks Been there done that. It's just so frustrating. The pharmacy at my hospital is not 24hrs, so night shift is always limited. If we need any meds, our supervisor has to get it from the pixis on another floor. In terms of MARS we, the nurses have to keep reprinting them in case we put in an order or the doctors put in the order. Those orders the docs put in come out of the printer. In my case the orders came in late, and we were so busy I didnt have time to see if there was anything in the printer. Hence, I caught the error at 4am!! Thanks for hearing me out.

Has anyone else made medication errors?? I'm so down in the dumps.

[KelRN215, BSN, RN]

The number of nurses who've made medication errors is surely far more than those who haven't. Nurses are human.

How do you sign off your meds? I can't say I was ever a huge fan of medication scanning but the situation you describe with the Xanax is exactly where it would help. If you scanned 0.25 mg and went to sign it off, you'd get an alert saying something like "ordered dose is 2 mg, you are administering 0.25. Do you wish to continue?" Also, how does your pyxis work? If you went to remove Xanax and it was 0.25 mg tabs, I would guess it would tell you to remove 8. My assumption is that this is how the next nurse caught the error, because there was an overage of 7 pills when she went to remove a dose. I don't know about your hospital, but in mine, we had to count controlled substances every time we went to administer them with 2 nurses.

If you think your manager was disappointed in you, it may be that she was disappointed because you didn't self-report the error with the Xanax. When managers find out something like that after the fact and it was never reported, it may seem to them that the employee was trying to "cover up" her mistake. I'm not saying that was your intention but, in the future, I'd write an incident report in that kind of situation.

[RN4116]

The number of nurses who've made medication errors is surely far more than those who haven't. Nurses are human.

How do you sign off your meds? I can't say I was ever a huge fan of medication scanning but the situation you describe with the Xanax is exactly where it would help. If you scanned 0.25 mg and went to sign it off, you'd get an alert saying something like "ordered dose is 2 mg, you are administering 0.25. Do you wish to continue?" Also, how does your pyxis work? If you went to remove Xanax and it was 0.25 mg tabs, I would guess it would tell you to remove 8. My assumption is that this is how the next nurse caught the error, because there was an overage of 7 pills when she went to remove a dose. I don't know about your hospital, but in mine, we had to count controlled substances every time we went to administer them with 2 nurses.

If you think your manager was disappointed in you, it may be that she was disappointed because you didn't self-report the error with the Xanax. When managers find out something like that after the fact and it was never reported, it may seem to them that the employee was trying to "cover up" her mistake. I'm not saying that was your intention but, in the future, I'd write an incident report in that kind of situation.

Thanks KelRN, on my unit we dont use a pixis, we have a locked narcotic box and log it in a kardex every time we give a med. We also do narcotic checks every day (oncoming and offgoing shift) The reason I didnt report the med was because the senior nurse told me it wasnt necessary and that it was a rookie mistake. Hence, why she didnt report it. I trusted her and I didnt worry. I would never try to cover it up. Later on I apologized to my boss and told her I would try harder. I'm just soo depressed over this whole situation. I really like my job and dont want to get fired. : /