someone's med error thread got me thinking: we've all made them. anyone who says he hasn't is either lying or too stupid to realize that he's made one. (or perhaps, in some cases, hasn't made one yet.) the difference between a good nurse and someone i wouldn't want taking care of me is that the good nurse recognizes the mistake, admits it, and immediately sets about mitigating the damage. a good nurse shows integrity.
that said, there are dozens of newbies out there agonizing over their first drug error and convinced they ought to quit nursing altogether because of it. all of us nasty, fat, old, smelly, mean and hidebound seasoned nurses know better. so let's share our stories!
My biggest fear, although I'm not yet a nursing student, is to make a serious med error. I have a math learning disability, and I'm so afraid that my dyslexia is going to cause me to make a problem. As long as I have access to a calculator, I should be OK, but I have to always check and recheck the numbers to make sure I am doing it right.
I'm concerned that I will take too much time, feel the pressure from doctors and/or other nurses from being too slow, and accidentally give the wrong dose. Has anyone ever had an experience like this before, specifically due to a disability? How have you dealt with it?
I am not a nurse YET, but I can tell you a med error that happened to my preemie (24 weeker). She weighed only 5lbs. at the time. She was back in the hospital for a staph inf. she got during an eye operation, and had to get a chest tube put in. A couple days after her chest tube was placed, we were moved out of the PICU. A nurse administered fentinyl very slowly, however she flushed the line very quickly. My little peanut turned blue, and had to be "bagged". When this happened, she got another pneumo-thorax. We were in the hospital for another week.
Making an error is devastating, but like Ruby stated it's what you do after that shows your caliber as a nurse. One of the worst errors I ever made (that I know of) involved amphotericin. My patient was receiving abelect (which is a milder form of amphotericin that is not as nephrotoxic and does not illicit the febrile reactions that amphotericin can). Anyway, I had pulled my patient's abelecet out of the fridge and checked the drug, dose, and patient name, but then laid it on the counter in the med room when I got called out of the med room for help. When I returned to the med room, I grabbed the abelect and hung it on my patient. Shortly after, my patient began shivering, and was extremely tachycardic and hypertensive. I immediately looked at the bag hanging and it was amphotericin ordered for a different patient!!!!! Talk about ******* your pants!!!!! I immediately stopped the drug infusion, administered tylenol, figured out the dosage he had already received and called pharmacy to have them give me the equivalent of an abelect dosage so I could let the physician know how much ampho he got and how much abelect he would still need, notified the doc, got an order for corticosteroids and the remaining abelecet dosage needed that night. Patient was fine. When reporting this to the AM nurse at shift change she asked, "You got an order for the Amphotericin dose instead of the abelecet dose to cover your ass, didn't you"? I was stunned. I said that no, it was not about covering my ass, but about doing what was best for my patient. I got an order for the remaining abeleicet dose and I got orders to cover his febrile reaction and I wrote an incident report. Geez! The way some people think! Scary.
When I was a new grad in ICU I hung a 20,000 unit Heparin bag on an arterial line....where it should have been 2 units/ml. YIKES...luckily the line didn't get flushed...needless to say it didn't clot off...
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
my ex, also a nurse, was team leading on a nephrology unit. most of the patients were on tpn. he lined the tpn bags up in a row -- room 1's tpn, then room 3's, then room 5's. on the other med cart room 2's, then room 4's, then room 6's . . . you catch my drift. then he started down the hallway and being very efficient, started hanging the tpns, one right after the other. only he hung room 3's tpn in room 1, room 5's in room 3, etc. all the way down the hall. nine bags of tpn. it wasn't until he got to the last room that he noticed his mistake -- the only bag left over was for room 1.
the right thing to do would have been admit his mistake and start to mitigate the damage. in al probability, most of those bags would have been ok -- most of them were a standard mix. he could have called the doctors, let them know, given extra glucose to the patient whose bag contained extra insulin or just thrown out and replaced the bags that were the worst fit for the particular patient they ended up hanging on. but my ex lacked the "honesty and integrity chip." what he did instead was run back to room 1 with room 1's tpn, remove the bag that was hanging keeping it carefully inverted and spike the correct bag. then he waltzed into room 3 with the correct bag of tpn, removed the bag that was hanging, and spiked the correct one. and so on down the line. years later when a group of us were talking about our worst med error either, he confessed. it was too late for me -- we were already married.
I haven't made a med error yet, but I've come very close.
I did a clinical at a rehab hospital. My floor had 40 patients, lots of diabetics, lots of people on corticosteroids, and 3 glucometers. Mealtimes often started with "Glucometer smackdown."
I had to take a fingerstick glucose on a patient at lunchtime. The MAR had 3 sheets for each patient: scheduled meds, PRNs, and diabetes drugs. I intercepted a glucometer, grabbed my patient's diabetes sheet, and went to the dining room. My patient was at the table with everyone else, but I didn't want to test him at the table (it struck me as rude), so I moved the patient to the corner. I figured the test would take 30 seconds. Then the glucometer shut down.
Without a code, I had to track down another nurse to set the glucometer back up. By the time I had it up and running, lunch was over, and my patient was back in his room. I ran into my instructor and told her what was happening. She wanted me to take the patient's entire MAR. I grabbed a folder from the right cubbyhole, took the FBS, and gave insulin per his sliding scale. My patent finally had lunch.
When I opened the MAR to document it, I saw a different patient's diabetes sheet. I had the wrong MAR. I had the right diabetes sheet, and I checked everything against the patient's name band, but I felt awful. The hospital had 3 different sliding scales, and if I had gone by the one in the MAR, I would have giving him triple the correct dose of insulin.
My almost-error taught me to always check the MAR and the name band, no matter how much of a hurry you're in.
Years ago working as an Army medic I had a Pt come in from the field with an abcess. I had about an hour before he left for another patrol so rather than try to get him into the Field Hospital I fixed him up and gave him some oral AB's. I went through the 5 Rights making sure to ask about allergies, no allergies no problem. Being a dumb grunt and not all that bright, he didn't know what allergy meant.
20/60 later he was in the resus bay with an anaphalactic reaction. I visited him the next morning in time to overhear him cheerfully telling the MO, "The same thing happened the last time I had those pills."
The MO was not pleased and I still bear the scars from that butt chewing. I learnt though and have been ultra cautious since.
I once had a very high strung resident who had scheduled valium four times a day. they were 25 miligram tablets and we had to break them in half to give her the correct does of 12.5 miligrams. iwas on orientation that night, and it was my first night having this lady. I didnt double check the dosing on the MAR. I gave the whole pill to her. when i realized my mistake on the way to the next resident i ran frantically to the nurse in charge who laughed at me and told me she also gets the other half prn. surely enough i checked the order sheet and she did get it prn, and after calling the nurse practitioner on call (who said the same thing) she ended up being fine, and had no anxiety attacks and slept thoughout the night. no ill effects, but boy was i tempted to call the NP back and ask her for a stat does of valium for myself!!!!!
I also had the family member from heck breathing fire down my neck while i wated for doc to clarify a the dosage for a roxanol sl order. well, i ended up putting my name on the physician order sheet, instead of the residents name. luckily the DON and the pharmacist had a sense of humor.
Years ago in LTC as a fairly new nurse: working 3p-7a start off giving meds @1600, 1800 etc. The activities department changed their daily board (you know the one with the day, date and list of events) after their last activity. So I have been passing meds all shift, look up and see the date on the board and realize I need to change the fentanyl patches. Changed three patches then caught it, it was a day early !!! I was freaked. Called the DON and had to call three different MD's to report. No harm done because obviously I had removed the old (and these were sched q72) and the MD's were actually pretty nice to me (I think they could tell by my voice that I was devaststed). Outcome: activities waited til next day to change their boards from then on!!!
Felt pretty foolish cause of course it got around, I mean how do you give all the meds, tx right for the 17th and change the patches for the 18th and not catch it? I don't know...but I did.
My biggest fear, although I'm not yet a nursing student, is to make a serious med error. I have a math learning disability, and I'm so afraid that my dyslexia is going to cause me to make a problem. As long as I have access to a calculator, I should be OK, but I have to always check and recheck the numbers to make sure I am doing it right.
I'm concerned that I will take too much time, feel the pressure from doctors and/or other nurses from being too slow, and accidentally give the wrong dose. Has anyone ever had an experience like this before, specifically due to a disability? How have you dealt with it?
I don't have a disability with math but when you are a nurse carry a calculator, can always double check with another RN and/or pharmacy. You'll have resources, so be sure to use them.
I may have mentioned this story before, but here goes....
My first med error (and as things go in ones career, the one I VIVIDLY recall the most) happened when I was orienting on days, my first job as a brand spanking new RN on an extremely busy ortho-neuro-gyne-med-surg floor (years later, my co-workers and I took to calling our unit 'The Dump' :icon_roll Anyway...)
I had an absolute KICK-ASS preceptor who'd been working there for decades. She was smart, talented, hard-working, dedicated and blessed with a dry sense of humor :) She rode my ass mercilessly all shift long, every single day at work. Her simple rationale: "I'm not trying to be a 'nag' but I'm trying to give you an idea of how hard this job really is. Make use of me, my time and expertise the best you can NOW... because in 6 weeks or less; you'll be ON YOUR OWN".
She scared me poop-less.... but she also made me sit up and take notes.
Now, all "background story" aside:
I was on my last shift of week 3 of orientation (heck, I even remember the day - September 23). I had a 79 year old post-op ORIF of the Left ankle. I'd gotten through the initial 4-hour period window of post-op patients with their constant monitoring... heck, I'd even gotten 70% of my documentation done. I grinned to my cocky self and thought 'this is going good'.
As are many patients who are post surgery, pt. developed nausea and vomiting. There was a standing order for Droperidol (Inapsine). I drew up the right amount, checked it against the MAR, and showed it all to my preceptor before walking into the pts. room to administer it.
I administered the dose with no hassle, flushed the port and after reassuring the family that the medication should help, left the room to chart.
15 minutes later, as I'm walking by the pts. room, I notice that she seemed drowsy. "Maybe pt. is just tired." I told myself; "After all, pt. has had a long day." I congratulated myself on the quick intervention to resolve pts. nausea/vomiting and my head ballooned with grandiose ideas of what a 'kick ass nurse' I was going to be.
Well, as they say - pride commeth before a fall.
Half an hour later, as I was walking by rounding on my patients, I noticed that the pt. I'd administered Droperidol to seemed to be in a REALLY DEEP SLEEP.
My "still-cocky brain" somehow managed to tarry a tad bit longer to ogle its fine work. Ahhh, she's resting so comfortably...."
That was when the "other" brain's screams became more audible.... "she's not breathing! She's not breathing! She's not bre...." (and so on)
As Siri would aptly describe it:
!! PANIC !!
Klaxons went off in my "cocky brain" and my bladder did it's best to burst past my sphincter and empty itself in a glorious waterfall onto my shiny new white scrub pants...
I somehow managed to "rush into the room" while also not outwardly appearing to "rush into the room". My mind was racing the speed of light and winning, while all my lungs could do was echo the "Oh my god! Oh my God! Oh my God" chorus... as my heart proceeded to jump out of my mouth and take off for parts unknown.
Outwardly, while I did my best to not appear to be the nervous debris that I was, I attempted a feeble smile at the family as I managed to croak "I'm just here to make sure XYZ is all right"... while my stomach was doing somersaults worthy of an Olympic gymnast medal.
The pt. was a 'little hard' to arouse. But to a noobie nurse like me, anything less that "full arousal" was = "comatose". Even though my heart was incognito, I could feel its rate climb into the Ionosphere. A cold, icy ball materialized in what was left of my stomach....
"Cocky-brain" had been replaced by "Panic-brain". "I killed the patient" seemed to be the medley of the moment - interspersed with "you are an idiot" and "how stupid of you" and various other choice epithets [i'm omitting a few phrases (ok, LOTS of phrases) because they probably don't even qualify for PG-50]....
Miraculously, from somewhere in the depths of my foggy (non panic-ky) brain, I latched onto an idea. I walked outside and brought back a portable pulse-ox machine. This way I'd have an idea of the pts. heart rate and oxygenation while I manually counted the respiratory rate and the blood pressure.
My initial readings were fairly "normal" (i.e. not too deviant from pts. known baseline and previous vitals)... save for the respiratory rate. For the rest of the shift, it hovered around the 12-14 mark (while the other signs stayed stable).
For the remainder of my shift (6 hours), I was in that room as often as I could (sometimes as often as every 5-10 minutes).
Throughout all this drama, my preceptor kept mum - except to encourage me to check in on that patient as often as I could while also hounding me about my other patients.
By the end of that shift, I was a wreck. I was convinced I'd nearly killed the patient. I had worse than a "lowlife no good slacker" opinion of myself. My report off to the night shift was very somber and gloomy.
As I plopped my weary butt down to chart after the shift, my preceptor mosied over and nonchalantly said "you want to talk about it?"
Dejected, head downcast, I mumbled "I'm so sorry. I don't know what happened. One minute pt. was fine but the next minute.... well; I don't know what to say!"
She simply asked "Well, what do you think happened? What do you think caused the pt. to become that way?"
"I really don't know", I stammered. "I wish I did!"; I said, somewhat emotionally.
"Walk me through it. Walk me through your interactions with that patient during the shift".
And so I proceeded to describe it all, in painstaking detail.
"Do you think any of the medications you gave the patient over the shift might have caused that?"
*Blink* *Blink* "Why, now that you mention it, the whole damned business started after I medicated the pt. for nausea!"
"Well, what did you give?"
"Inaps.... wait a minute!"
"How fast did you give the Inapsine? Did you give it slowly over a good 1-2 minutes?"
I thought real hard. And then it hit me - in my eagerness to relieve my pt. of nausea/vomiting; I might have slammed the medication in too fast. 0.625 mg didn't seem like "a lot" to my dumb-brain... but I'd forgotten to take other criteria into consideration. Not to mention the cardinal sin of administering a medication I wasn't too familiar with - especially with regards to effects AND side-effects.
My face turned a beet red: "I... uh... might have... ummm ... given it a little too fast".
My preceptor smiled and winked at me and said: "Lesson learned".
I was thunder struck!! "WAIT!", I sputtered; "you KNEW all along??!! WHY didn't you tell me???!!!"
"Because I'm here to teach you and you're here to learn. Knowing you, I'm rather confident that after today - you will never give any medication without knowing what it can and cannot do... and how to give it appropriately. Being a nurse is more than charting meds and giving them as ordered - as you've no doubt learned today."
She reached over and patted my back and said: "Don't beat yourself too much over it. I was observing the patient all along too. Your subsequent reaction to the patient's status is commendable - if a little inefficient. But, you're learning and you attempted to do the right thing; which is what counts any way. Someday, I'll share my own 'learning lessons' with you. But for now, finish your charting and I'll see you tomorrow".
It's a mark left in the only place that counts. No matter how old or how experienced you get...
You never forget it.
Cheers,
Roy
PS: Congratulations if you made it this far into my banal story
ToxicShock
506 Posts
My biggest fear, although I'm not yet a nursing student, is to make a serious med error. I have a math learning disability, and I'm so afraid that my dyslexia is going to cause me to make a problem. As long as I have access to a calculator, I should be OK, but I have to always check and recheck the numbers to make sure I am doing it right.
I'm concerned that I will take too much time, feel the pressure from doctors and/or other nurses from being too slow, and accidentally give the wrong dose. Has anyone ever had an experience like this before, specifically due to a disability? How have you dealt with it?