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!
I am so glad this thread was started. I am a nursing student. I made a medication error and I can't get over it. i gave too much insulin. I know there is a 2nd verification. The only miserable excuse I can offer is that I accepted my preceptor telling me how many units right outside the med room door as a kind of verification - two people had confirmed the amount. I knew it was a visual check, but in my short time in the hospital, I, along with my fellow students, have all seen that a lot of people don't follow those rules we are taught (including insulin verification, 3 MAR checks, 2 identifiers, etc) as a method of getting everything done in a shift that needs to be done. As for why I pulled up the wrong amount in the first place, I don't know. I just don't know. I am at fault all the way around, no doubt. To my credit, as soon as I walked out of the room, I was running it through my head and realized the stupidity of my error and literally ran and grabbed the first RN I saw. Within 3 minutes, corrective actions were underway, MD notified, pharm notified, FSG orders in place, etc. Only harm to patient was the additional fingersticks (which hurts my heart still). I have not been incompetent in the past. I have received rave reviews from preceptors, patients, and faculty on my clinicals. I am an A student who knows how to do insulin, how insulin works, the whole 9 yards. Now, I can't get this out of my head. I am going to be allowed remediation and as long as there are no more errors, I will not be kicked out. (And trust me, I will NOT be making any more...I will be the stickler for the rules forevermore. Period.) I am consumed with the fear and shame. I can't believe that I could make such an error, especially when I know better! It is always on my mind, and I can't come out of the funk. I have heard all the "you made a mistake but showed great integrity and concern for your patient" and one nurse even told me "we can teach the students skills, but we can't give them a heart. You have a heart, you will be ok." Personally, I just want to die. Maybe not die, but the thought did occur to me to step out in front of a car on the way to class Friday to avoid having to face the possibility of getting kicked out. Then I would be poor ____ got hit by a car and had to quit school, not stupid ass ____ almost killed a patient and got kicked out.... How long does it take for a truly compassionate person to get over the potential of her actions to take someone's life and shame of a mistake that should not have been made? :bowingpur
]Roy Fokker, that sounds like one heck of an awesome preceptor. Seems like a story not only to help new grads who make a med error not feel so bad, but also a lesson on precepting. Nice.
Chances are, I've made more than this, but my first med error always stands out in my mind.
I was a pretty new nurse...night shift ICU. Had this patient who had bilat AKA, huge sacral decub, and on hemodialysis, who coded in dialysis. I picked her up that night and had her for 5 nights straight. She circled the drain the whole time. Maxed out Dopamine one night so we started Levophed. I'd never used Levophed before so I looked it up quickly and then bounced it off one of the more experienced nurses..."How much should I start with?" "Oh, about 2 mcg." So I programmed the pump...130 ml/hr seemed a little high but J. told me, right? So the blood pressure cuff went off. 143/60??? I hadn't seen a pressure with a systolic higher than in the 90s since she'd been there. I brought J. in the room and she said, "I bet she's perfusing parts she forgot she had!" She then looked at my pump, I was supposed to do it in mcg/min but I had done mcg/kg/min. She helped me fix it. Patient finally died on me the following night...
Speaking of Inapsine, it always "snowed" my patients, and one time I thought my patient's decreased LOC was med side effect when she actually had an intracerebral bleed cooking...I almost quit nursing over that one. Another example of needing a good mix of experienced nurses. We had one RN that night with more than a year's experience, and she was so angry that our NM had started letting anyone who'd been there longer than a year be in charge and not have to float that she did not help me out at all. When I asked her to look at my patient, something didn't seem right, she told me to ask my charge nurse (a guy who'd graduated a semester before me and was just as clueless as me). They changed that policy after that patient died. In retrospect, there probably wasn't anything that could have been done, I'd been calling the doctor all night because of blood pressure problems and begged him to come see the patient, but he wouldn't. The outlying hospital had given Retavase without lowering the patient's blood pressure sufficiently first and that's what caused it. But the fact I missed it...newbie mistake.
Great thread! To my knowledge, the worst I have ever done was missed the "1/2 tab" on the handwritten MAR and gave Lipitor 40mg instead of 20mg. I didn't realize it until the next night when I had the patient again and noticed that it was a HALF tab. Not a big deal in the scheme of things, but you can bet I've been super-careful about dosages ever since. It could have been something very important! Every med error anyone has ever shared with me, or that I've caught on someone else, I've taken to heart because no one is perfect and it can happen to anybody. I've seen some truly hair-raising things happen but have never personally witnessed anybody die or have lasting damage due to a med error on my floor. One that really sticks with me was the cocky nurse who has been there for ages, who LIVES to ride the newbies and make their lives miserable, give an entire handful of meds to the wrong patient. This included meds for diabetes and hypertension, neither of which that patient had. Fortunately patient was fine, but had to be frequently monitored with accu-checks and BP checks. The patient was elderly and not at all familiar with what meds they were supposed to be taking. Always check that nameband and KNOW WHAT YOU'RE GIVING AND WHY. If a med seems inappropriate or the patient questions it, take the time to research it! I've had some near-misses that I luckily thought to question before giving.
Like I said, I only know of the Lipitor I gave...but there may have been other things. I feel really bad for nurses that beat themselves up for days over med errors but I understand the feeling.
My almost errors during my first year: PRN Haldol "DO NOT GIVE IV"on each bottle. I wipe off the IV hub with my alcohol, look at my syringe, bug out my eyes, get the chill that goes down the body leaving the nose cold, and then give it IM. "Whew"
Give my oral cardiac meds, listen to "I never had that pill before" in a little shaky voice. After the 50 yard dash to the med cart and back, hearing: "O yea, I remember."
Then the real errors: Hanging the antibiotic and walking out, then walking back in to grab the water pitcher and the bag is empty."
And years later in the NICU, the dopamine in hub...flushed, staring at the monitor, I was OK again. Oh yea, so was the baby.
Recently, changing clothes at home: "Huh, whose Mylacon is this?"
I guess that's about it.
PS Only one med error on my floor when I first started: Mine... RIGHT No one filled out incident reports! That changed.
I just wanted to say thank you to everyone for sharing their experiences. I am in my 2nd semester of Nursing School and hearing these stories is a reminder that errors DO happen and it is important to be diligent!
Now, I have only been giving meds to pts for a few months now, and luckily haven't enountered a med error (that I know about, that is...) I will share a story that happened to someone in my clincial group because I think it could easily happen to anyone. She was administering a PO medication, did her first check against the eMar and the Pyxis...went to the pt's room and verified the name/dob. She went to check the meds again agaist the eMar and realized that the medication that she was about to administer was not even close to what she thought she had pulled. Come to find out, pharmacy had placed 1 sheet of medication A into medication B's pocket in the Pyxis, so half the drugs in the pocket were med A and half were med B. If she had been rushing or hadn't made sure to do that final check, she very easily could have given the wrong medication. Just hearing the story has made me diligent about the 5 rights/3 checks!
When I was a brand new grad, I gave a lady post-colectomy a bag of Mefoxin when she was ordered Zosyn. She was fine, I called the doc and she told me not to worry about it, that Mefoxin was actually better post-abdominal surgery than Zosyn. I wrote an incident report, and that was that. No harm done.
I gave Colace and iron to an antepartum pt that wasn't mine. I just went in the wrong room, and fortunately, she was ordered the same meds at the same time. Colace & iron are pretty standard meds for antepartums at my place. I just let the nurse taking care of her know what I'd done so she didn't get double dosed.
Oh, and let's not forget the time thought I had popped the cap off the IV abx but really hadn't. So basically my pt got 50ml of NS for their cellulitis.
I've only been a nurse for about six months and the only med error I"ve made was I didn't set the IVF rate properly of some normal saline that was running through a burrette - essentially it was because I hadn't learnt how to ID how fast the drips are and what that translates to an hourly rate.
As for other drugs, I am so damn paranoid about the situation and my dyslecxica I check at least three times, and even feel sick pushing IVAB even though I know its the right patient!! But my paranoia has paid off, I was once about to give a pt a drug and I asked them if they had any allergies, even though they had "NKDA" listed on their charts, they then told me they had an allergy to the drug I was about to give! I asked them if they had told the doctor, they said they hadn't! So in quick discussion with the doctor we had the AB changed. IF I hadn't asked, and had given the IVAB the pt would have probably died - it then amazed us all that the pt knew about this allergy and how serious it was and hadn't endevoured to tell the doctor!!!!!
And a SN made me even more paranoid the other day when she told me that when you inject KCl into a bag of fluid to make sure you shake the heck out of the bag because someone didn't shake it and the pt got a fatal dose!!
Of course, I do acknowledge that eventually, one day I will make a mistake and i'm more then willing to take whatever consquences come my way - knowing i could screw up, sort of makes me so aware that I don't want to screw up and go to efforts to make sure I do everything in my power to not screw up.
I'll never forget this one. Way back in the day, narcotics were kept in a locked drawer. We had little divided bins, like you find in a craft store & everything was hand counted by one member of the off-going shift & one member of the on-coming shift.
After giving out my 9pm meds, a patient called saying "I think I'll take that sleeping pill after all." I got it out & gave it. When the morning came we were over 1 of the 10mg & under1 of the 25 mg.....
I knew immediately what I'd done. 10mg ordered, I gave the 25. I called the doc & told him what I'd done....he ordered a one time dose of 25mg. so I wouldn't have a med error (God Bless him) & the patient said that was best night sleep she'd ever had.
SMH RN2B
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