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!
Just recently I underdosed someone. I work in a prison infirmary and we had a trainwreck of an inmate here. We get our Vancomycin in vials to be reconstituted and then added to minibags; it comes in 1g vials and the order was for 1.25g. I didn't notice this until my 3rd night, of course. What's worse is that I mixed the bags for the oncoming nurse, as a courtesy, and the doses were all wrong there, too!
I called our medical director, filled out the proper forms, the guy died anyway. And not for lack of antibiotics but still.
Once when I first started working here I gave an entire envelope worth of pills to the wrong inmate. Including a narcotic.
And I've totally done the entire bag of stuff infusing in 10 minutes thing. We don't have pumps here, we have these 'flow regulator' things that are dials on the end of the IV tubing. I set that to a respectable rate and clearly I did it incorrectly because the next time I glanced into the cell that bag was empty.
Great thread! I agree that everyone will make mistakes and the mark of a good nurse is what he or she does after the mistake is recognized.
Specializes in Peds Urology,primary care, hem/onc.
My first year of nursing, I worked on a pediatric hem/onc/bmt floor. A lot of our IV meds where made by the pharmacy in 60cc syringes and given on syringe pumps. All of the IV meds in syringes where in one bin (hindsight tells me now that is a bad idea but this was 10 years ago). I had a patient on an IV antibiotic (cannot remember which one but it was clear) and IV Zofran. The volume for each med was the same and both where in a 60cc syringe. In the middle of the night, I looked in the bin for the antibiotic, saw it, grabbed it and hung it without checking it again in the room. When the pump was done, I went to take it off and looked at, it was the Zofran and I had given it about 3 hours too early. Learned that lesson, ALWAYS check it the last time just before you hang it. It was the one time I didn't, and I made a mistake. Looking back now, the way the meds where stored was a mistake waiting to happen, but I still remember it 10 years later. I know I made other errors as well that I cannot remember off of the top of my head...but this one sticks with me 10 years later because I had been so diligent about 5 rights/3 checks and the first time I slacked on it, I made a mistake!
While I was not responsible for this error, I witnessed it....twice.
We had an agency nurse from the Netherlands who had never loaded MSo4 in a PCA pump. Instead of asking for help, she went to the pixis....entered her info. The vials (1:1, 3:1, & 5:1) were all in the same drawer together. Her patient was ordered a 1:1 with a 6 minute lock out. She loaded a 5:1.
Need I say more? The same nurse made the same mistake with the same patient 2 days later on another shift.
Except this time his wife was there. Every time he moaned....she hit the button. When I made rounds I found him, blue & barely breathing. We hit him with an amp of narcan & he was sent to the ICU....he lived.....but whew!
After that we only kept 1:1 amps in the pixis, all others had to be ordered from pharmacy. We also had family's sign a form stating that they understood that PCA meant 'patient' controlled.....not family controled.
Now....this error happened because we had nurses working 12, and some working 8 hour shifts. The nurse that clocked out at 3p handed her patient load over to a new grad she neglected to tell her that 3 of her patients were accu-checks ac, tid. The nurse that took over missed those evening accu-checks. She discovered the error when she went to document & saw the diabetic flow sheets in the chart. Not life threatening, but you can see the importance of communication between out going/on coming staff.
As a student in my last semester (preceptorship): Pt. had NS TKO and an abx q 6 hrs (Zosyn I think?). Rather than piggyback it my preceptor and I stopped the NS to run in the abx. Pt. asked for a PRN med (I can't remember if it was for pain or nausea now), but it was to be given IV push. I told the preceptor "I can't give this through the same line, right?" Meaning the abx. She thought the abx had stopped running and the pt was back on NS, or else she forgot that we hung the abx. She says "Oh, no you just give it through the same line". I even double checked, "are you sure", she says yes. I drew up the med and went to give it, all the while feeling very wrong about it (lesson: LISTEN TO YOUR GUT). I pushed the meds through the same tubing as the abx and it immediately crystallized in the line. I saw it and clamped/removed the line immediately so the pt. did not get any of it, but STILL! PANIC!! Called the preceptor in, still shaking. The abx was empty anyway so we threw it away, resited the IV just in case (it was due for it anyway) and re started the NS THEN gave the push.
My preceptor was great about it, she took responsibility because she forgot the abx was running but I still felt terrible because I KNEW in my gut it was wrong but I did it anyway. She gave me credit for having that gut reaction and just told me to listen to it next time!
I had a near miss recently. As a school nurse, almost gave a kid the wrong inhaler. He had lifted it almost to his lips and he said offhandedly, "mine used to be blue". Immediately realized what I had done and yanked it out of his hands before it touched his lips. Two kids had VERY similar names (think something along the lines of Jose and Jesus with a common hispanic last name), and I had the inhalers by alphabet. After that near miss I changed them around!
Specializes in Emergency Dept. Trauma. Pediatrics.
Well I don't know whether or not to be traumatized after reading this thread or relived LOL. Honestly though, it's a great idea for a thread and makes me feel a little more prepared for when I start. I have been in the hospital for surgeries and stuff a handful of times, won't even get into my experience with a few of the Naval hospitals as a patient. Like the 8 sticks to get an IV going right before Surgery, The Anastesiologist finally had to come in and do it and then they joked about it saying well, this is the naval hospital. Yea it was my first surgery and I busted out into tears. Anyway, my most recent Surgery was a hysterectomy in August 07 at the Hospital I will be doing my clinicals at and hope to work out, they had a very strict medication policy. Each medication I was given down to stool softeners was scanned before administered and my bracelet scanned. It took a little more time but I am guessing there medication error rates are way down from it.
I had my daughter at another hospital that was 30 mins awayand I might have to do clinicals there as well, they didn't have this sytem and a senior nurse there made a couple of pretty big doozies when it came to my labor even when I insisted she check my contractions (the monitor wasn't registering and she kept upping my poticin and I informed her the monitor isn't working and I was having very fast and painful contractions. Only half my epidural worked so I could feel them on half my side very severe, It was my 4th child so I was not new to this) anyway, when I doc came in and got into a fight with the nurse there and got some internal monitors in I was almost rushed to an Emergyncy C Sections because my baby got so stressed and kept having major D Cells. Anyway, I got way off track, but I thought the scan system was really good.
Great thread! I haven't started work yet, but I had a near miss in school. I was giving insulin to a patient and my preceptor pulled the syringe out of the drawer for me and told me to pull it up and go ahead and give it while she went to check another pt.
Well, bells were all ready going off in my head about not having her there when I was to give the insulin, but I just did what I was told. So I draw up the insulin and it looked like an awful lot of insulin for only 6 units. It practically filled the entire syringe. I definitely knew something was wrong so I went looking for my preceptor. Couldn't find her. So I got another nurse to check it for me. She said it was fine. It was the right dose.
Still didn't feel right about it, so I go looking for a 3rd opinion and then I hear the nurse I just asked running after me. She checked it again and we realized at the same time that I had the wrong type of syringe. I hadn't looked at the package and was just assuming that my preceptor gave me the right one.
So, the situation was rectified, and I made sure my preceptor was with me when I gave it. I felt really stupid after that one. I learned a couple of lessons that day, though.
1)Don't think the preceptor doesn't make mistakes even if they are more experienced than you.
my first job was in LTC. i had oriented for 2 months with the most wonderful "old" nurse. so it was finally the day for me to go on my own. there were 2 Mrs. Smiths, literally across the hall from each other. martha had drilled in me to be careful with these 2 patients. needless to say, my first day alone....i gave them each the other's meds! i was horrified and cried and cried.
few months later, same place, i was starting a man on po antibiotics. he was allergic to PCN. the med ordered was augmentin. i knew that augmentin was amoxicillin but for some reason it didnt register in my mind. so as i put the med in his mouth, his wife says "he had an anaphylactic reaction to PCN and almost died. thats not PCN is it?". i tell her "oh no, this is augmentin". and as he swallowed it, it hit me like a ton of bricks what i had just done! i sat by his bed for hours after i called the doc, the DON and anyone else i could think of. thankfully he was OK but you bet i've never done that again!
a couple years ago i was writing discharge meds for a patient. at the time, the doc would sign the prescription sheet and then i would write the meds on it for her, AFTER she signed it. seemed like a great policy to us at the time, lol. so a week after the guy goes home his dialysis ctr calls me to ask me when he'd started on a cardiac med that was new to his list. i pulled the chart from medical record to find out for them and realized it was an error. but i didnt realize it was MY error. the doc was in the building so i showed it to her. as she's looking at it we are saying "what idiot did THAT?". suddenly she starts laffing and says "um..wen...YOU are the idiot!". i almost died! i had transcribed the drug wrong. i had looked at the order and then completely wrote something different on the med sheet! i had to call the dialysis ctr, the man's sister who was his caregiver, his PCP...and everyone i could think of. the sister actually tried to sue us over my error too so i also got to meet Risk Management and the company lawyer. there was no harm done to the patient thank the Good Lord! but i was devestated nevertheless.
thanks for letting me share my doozies, lol. great thread miss ruby!
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.
one of my LTC pts went south last year and had Levophed in the hospital. unfortunately it infiltrated. after a few months of trying to save her arm, she had to have it amputated and eventually died from complications. i felt so bad for the nurse at the hospital. she called and checked on her daily for months. no matter how many times i could tell her "it's ok" she couldnt forgive herself. my heart would just break talking to her because you could hear it in her voice that she was devestated. even the patient didn't blame her but you couldnt make the nurse believe it.
I've made a number of drug errors that I know of, usually caught when a patient picked it up ("I usually have the yellow tablet in the morning/why is there only one blue tablet?" etc), and I'm sure there are hundreds I've made without knowing about - research indicates that if you give more than x (around ten) meds in an hour you'll make an error, and there are days where I give four patients a dozen meds each within the first hour of the shift. Just because I don't catch them all doesn't mean I think I make errors less often than the statistical average (though that'd be great!).
There have rarely been any ill-effects, at least as far as I know, but of course you can never know all the ramifications of undetected errors - did I overlook a dose of antibiotic that lead to Mr Y's resistant bug? Was Mrs Z's jump in INR because I gave the wrong dose of Warfarin three days earlier?
But there are two mistakes I'll always remember, even though nothing happened to the patients. The first was when I wa a final year student in my hospital-based program. I was working on an oncology unit, where the huge doses of narcotics prescribed blunt your perceptions of 'normal' dosing. It was in 1991/1992, well before OxyContin, fentanyl, or patches, and we had a young guy getting a gram of IV morph an hour, with breakthrough doses of 300mg every 20 minutes PRN, so big doses weren't unusual.
So the ACN and I check a morph dose for our patient, a woman in her mid-fifties: 50mg IV. We check in the drug room as we sign it out in the register, again when drawing it up on the prep bench, and again before heading into the patient's room - Mrs X, morphine, 50mg, IV, 4/24 PRN. We check her ID band against the chart, and the ACN chats tot he patient as I flush her IV, I'm just about to pierce the stopper with the needle when the ACN tells me to hang on and, haivng just noticed the allergy band, asks the patient what she's allergic to.
"Morphine, dear."
Very quiet: "What happens what you have morphine?"
"I stopped breathing last time - I'm not sure what happened after that."
We excused ourselves, retreated to the panroom outside and took another look at the chart - the order was for pethidine.
On any other ward the dose alone would've been flag enough...
The second error was in my staffing year, about ten months later. I had an ill but stable man in his sixties admitted from ED late in the shift. He was on a bedside monitor, had a couple of lines running, and was overdue half a dozen meds. I really didn't want to leave anything for the night staff, and was worried that he'd get worse without the meds, so I checked them with another RN and proceeded to give them one after the other. I'd looked up everything and knew what was compatible with which fluids, what I could push and over how long, and what I'd burette at the end. I had a sequence in mind, and after I slowly pushed and flushed the diluted gentamycin (which we don't push any more), I got the Lasix. Only, as I finished the push I suddenly realised it wasn't frusemide, because that was still sitting in the kidney dish. Instead I'd pushed the (burette-only) digoxin.
I watched his monitor like a hawk for the next forty-five minutes, and got to know him very well for the rest of his stay, never losing a feeling of special responsibility.
There is nothing like the bowel-loosening terror of realising you've screwed up and potentially endangered a patient. So far that sensation's never been followed by actual culpability, and I know that while some of that's down to my competence, there's a solid helping of plain good luck in there too.
wow!! omg icu drips are soo incredibly dangerous! i work in a step-down icu (a new grad, 2 weeks so far) but the potential is there as well. i am sooo paranoid. i pushed lasix on a chf trauma patient today and my patient started hiccuping and coughing and i freaked out inside. but it was just a coincidence. i think orientation is taking years off my life! lol! :oornt:
Unfortunately it does happen. I have made a few. On the day shift which is crazy and we have 8 patients, families demanding all you're attention, all pt's on telemetry I was rushing as usual. My patient had a feeding tube that the MD orders stated crush all meds through NG tube. Chart checks were done which means 2 nurses checked it and wrote it on the MAR. When it was my my time to give it the patient was already 4 hours late for meds because of being off the unit for tests. So when she came back I was in a hurry to get these in. BP was checked, pulse before meds. all ok- well I crushed all meds as per md and mar order. One of the pills was an extended release BP pill and I didn't pick that mistake up and gave it crushed. 24 hours worth of med in 1 shot-CRAP
Her pulse 38 bp 60/40. I felt awful. Even though I was the 3rd nurse in and the MD wrote it I was still the one who gave it. The MD was very good about it, thank god. Gave fluids and rode it out she was monitored for hours
You just have to realize you made a mistake and take care of it quick. We're only human and stress is a powerful thing
I've made two errors that I can think of off the top of my head. First one was giving Metoprolol instead of Metoclopramide. I believe both meds looked similar. I don't know how I ended up finding my error, I think it was because there was actually no metoclopramide (reglan) card in the resident's section of the med cart (we use pop-out cards). No harm done to patient, thankfully.
2nd was actually this past saturday. I was in a hurry to get my med pass done, and if you work LTC you know that many residents' meds don't change too frequently unless they are acutely sick or on coumadin. Anywho, I gave insulin to two residents, my last two of the morning. Gave it to patient one, who was receiving her sliding scale, the other went to patient two who gets her NPH regularly every morning. As I gave insulin to pt. 2, I thought "hm, that plunge was quick!" Realized I had given pt. 2 pt. 1's 2 units of regular instead of the NPH, and the NPH to pt. 1 who should have received the sliding scale!
I've also questioned myself on morphine sulfate before, and it almost made me lose my crap a couple of weekends ago. We had a woman actively dying, so she was receiving 5mg morphine q 1/2 hour SL prn. At the end of the morning, I had remembered the 3-11 nurse checking a dosage with me 0.25ml. When I gave morphine to the resident, the available dose (in the bottle) was 10mg/5ml. Basically the syringe/plunger we were using to admin. to her was a 1ml syringe. I was giving this woman 2.5 plungers full, and I wondered if I was wrong, or if the 3-11 nurse had messed up. It was an awkward night, and the woman died about an hour after I gave the morphine, but I kind of hoped that, even if it was my error, this woman went peacefully.
Sadly to say, I have always been super careful after making an error, and have never repeated the same thing twice (as far as I know).
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humglum, BSN, RN
140 Posts
Just recently I underdosed someone. I work in a prison infirmary and we had a trainwreck of an inmate here. We get our Vancomycin in vials to be reconstituted and then added to minibags; it comes in 1g vials and the order was for 1.25g. I didn't notice this until my 3rd night, of course. What's worse is that I mixed the bags for the oncoming nurse, as a courtesy, and the doses were all wrong there, too!
I called our medical director, filled out the proper forms, the guy died anyway. And not for lack of antibiotics but still.
Once when I first started working here I gave an entire envelope worth of pills to the wrong inmate. Including a narcotic.
And I've totally done the entire bag of stuff infusing in 10 minutes thing. We don't have pumps here, we have these 'flow regulator' things that are dials on the end of the IV tubing. I set that to a respectable rate and clearly I did it incorrectly because the next time I glanced into the cell that bag was empty.
Great thread! I agree that everyone will make mistakes and the mark of a good nurse is what he or she does after the mistake is recognized.