Med Errors: Share Your Stories

[Ruby Vee]

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!

[elthia]

My worst, it wasn't a med error, it was an allergy error.

I took over a pt at 1900, the pt literally had about 50 allergies, one of which was latex. The hospital had changed it supplier for gloves, and it didn't click to me that some of the gloves in the pt's room were latex (the medium gloves and x large) and some weren't ( small and large). the boxes all looked different.

The pt was really sick, post CABG, and huge distended belly, no BS, and I KNEW she had an obstruction, but the PA I kept calling wouldn't given me an order for a NG tube. Well I got an order for a KUB xray. 45 minutes later.... The pt started c/o of difficulty breathing, I went into her room and one side of her face was completely red, I immediately called Rapid Response. By the time they arrived she was starting to wheeze, by the time it was decided to bring the ICU doc into it, her soft palate was starting to swell. She ended up being a difficult intubation x3 tries, we almost had to trach her on the floor. No ICU beds, bagged her on the floor for 2 1/2 hours while we played merry go beds in the hospital.

I wasn't disciplined, but it sticks with me....

I'm a bit fanatical about allergies, and checking to see if all latex items have been pulled from the room now.

[ncglazergirl]

When I was in nursing school, the day came that we had to give IM injections. Of course you are nervous

when you are sticking someone for the first time, but you also have to figure out correct dosages. We were on the surgical floor that day giving pre op meds. I was excited but scared. My instructor was there as got the dosa of versed ready. The patient should receive 2 mg. The vial contained 5mg/ml. There were 2 cc's in the vial. So, after carefully checking all the information, I drew up 2 cc in the syringe. I took my syringe AND my paperwork to the instructor. She checked me off. I gave the injection.( I know what you are thinking...oh no! 10 mg!) It was an awesome stick and the patient said he hardly felt it...I was so proud. That is until they called me from the OR. Turns out going down in the elevator the patient had to have his airway held open he was so out of it. They canceled his surgery for the day. I was completely mistified. I went back over the paperwork with my instructor.

Obviously it was our error, but the the way the MAR was written was confusing...I felt terrible when i realized what happened. But, what happened next was worse. I was standing there in the hallway and the man's son in law came into the hall. 'I can't believe you gave him the wrong medication! I am a lawyer and I can sue you for malpractice. This is negliegent behavior.....' I don't remember everything he said. I looked up at him, feeling so alone and threatened, and with tears in my eyes I said,' I am so sorry..'.

I went home and sat in the bathtub and cried until the water got cold. I had never felt so bad in my life. I thought that i was not fit to be a nurse...what was i going to do with my life? I called my mother, an RN, who said ' Honey, we all make mistakes. what is important that we learn from it, and that the patient is okay.'

Even though he WAS okay, i felt awful. The next couple of days i spent a lot of time thinking and i decided the only thing to do was go to talk with the patient. I went to Mr. X's room and i went in and told him i was the one who had overdosed him and told him how sorry i was. There was an RN there passing meds when i talked to him. He didn't say much, i think he was surprised. I was crying when i left that room. She grabbed me and hugged me really tight and told me it was going to be okay and how i was going to be a great nurse. She made all the difference that day...and in my career. I just remember hugging her and crying, and i didn't feel quite so alone anymore.

Now, 22 years later,I have made more errors than that (but none so dramatic or harmful) and I have learned from each mistake i have ever or ALMOST made. We are all just human, and so long as we truly do our best and are sincere in our efforts, we can carry on. Having integrity in nursing and being conscientious(spelling?) are two values we should all hold dear. So, new grads and nursing students, hang in there...and always do your very best, and always be honest with yourself and your patients.

[Ruby Vee, BSN]

that's a great story. bless your mother -- we all make mistakes and dealing with them with honesty and integrity is the difference between a good nurse and a bad nurse!

i'll never forget my first im injection on a patient! he was an etoher admitted for dts, and was to get a vit b injection. in those days, it came in a glass "tubex" and we used a metal tubex holder to give the injection. they looked pretty scarey. i checked the med carefuly with my instructor, carefully picked out and cleansed my injection site and then oh-so-carefully stuck the needle into the guy's buttock. at that point, he must have decided he'd had enough of all my painstaking carefullness, because he he lept from the bed and went tearing off out of the room, his butt hanging out of his hospital gown with the needle still protruding. the tubex holder flapped up and down a few times with his steps, and then fell out of his butt and the glass smashed all over the floor. i stood there with my mouth hanging open, in tears because i'd blown it. my instructor laughed so hard she wet herself!

[starletRN]

that's a great story. bless your mother -- we all make mistakes and dealing with them with honesty and integrity is the difference between a good nurse and a bad nurse!

i'll never forget my first im injection on a patient! he was an etoher admitted for dts, and was to get a vit b injection. in those days, it came in a glass "tubex" and we used a metal tubex holder to give the injection. they looked pretty scarey. i checked the med carefuly with my instructor, carefully picked out and cleansed my injection site and then oh-so-carefully stuck the needle into the guy's buttock. at that point, he must have decided he'd had enough of all my painstaking carefullness, because he he lept from the bed and went tearing off out of the room, his butt hanging out of his hospital gown with the needle still protruding. the tubex holder flapped up and down a few times with his steps, and then fell out of his butt and the glass smashed all over the floor. i stood there with my mouth hanging open, in tears because i'd blown it. my instructor laughed so hard she wet herself!

i just pictured that scene in my head. hilarious!

[Not_A_Hat_Person, RN]

I made a potentially fatal med error last night. I'm an RN at an ALF. Some patients are getting hospice care, some are on large amounts of opioids.

Last night, I had a patient who was getting 4 mg of Dilaudid. The last time I worked, she had a bubble pack with 1 mg tabs, and we were giving 4 of them. Apparently, they switched to 4 mg tabs over the weekend. Someone mentioned during count that "we only have to give 1 now," but the MAR was unchanged, and no one mentioned the new tabs in report (it has happened with other meds). So I gave my patient 16 mg instead of 4 mg Worse, I did it twice. I noticed when I went to sign the narc book, and noticed that the other nurses and techs had given 1 tablet.

I immediately talked to my supervisor, and ended up talking to the DON, the MD, and the family. The night RN and aide monitored her respirations for 4 hours. The patient had been on the drug for a while, and built up a tolerance, and Dilaudid has a short half-life. The patient was fine. I was terrified. I saw a lot of heroin overdoses as an ER volunteer, and that was the first thing that came to mind. I could have killed her.

I'm off today. I will have a longer orientation, and I will be meeting with the DON tomorrow before my shift. At this point, I'm just glad to get a second chance.

[vashtee, RN]

I made my first med error yesterday. Thank goodness it was also a mistake on the part of charge nurse.

Anyway, PRN blood pressure meds had the wrong parameters transcribed by pharmacy, and I didn't think to look up the original order even though they were clearly odd, but I DID check with my charge nurse before giving the med, and she said to give it because the pt's BP was high.

Fortunately, the pt. was asymptomatic.

[erin01]

i was a nursing student and i was given a patient who was d/c ..so last minute change of plans. My teacher asked me to get a new patient and give meds. I look down and i am not joking this patient had 15meds! well i did m darndest y to read through it all look up side effect. But the next day my teacher made an announcement saying that a med error had occurred and that there were not going to give out names. Well after the speech was over i went up to her and asked if it was me. I had had a feeling because i was so overwhelmed with all the meds. And she told me that it was, and that it was good that i had realized it and we talked about it. I learned a lesson and i will always try my hardest to not make mistakes but we are not perfect.

[teeniebert, LPN]

I've had 2 major errors that I know of. The first was several years ago. I had a little more healthcare training than my co-workers, so I was administering meds to a bunch of kids at an outdoor program. There were 3 kids named "Anna" in the program, and 2 of them had meds. When I told the group leader I needed "Sarah, Jamie, Eric, and the 2 Annas" to come take their meds, I ended up with one right Anna and one wrong Anna. 'Wrong Anna' came up first, looked at the (labelled) med cup and said "that's not my last name." So I picked up the other Anna's med cup and dumped the pill into her hand. Didn't ask what her last name was, I figured it must be right...I didn't find out there were 3 Annas until an hour later, when the 3rd Anna came in and said she didn't get her pill before lunch. :uhoh21: The staff watched 'wrong Anna' very closely the rest of the day; she was a little sleepy but otherwise fine. Her mother was very understanding and was glad that there were no lasting effects. The mom of the 3rd Anna was livid. She used the word 'inexcusable' in her tirade to me so many times that I still can't use it myself without cringing. The program director reimbursed her for the cost of the pill, and that was when we discovered that there was no medication policy on the books of the sponsoring agency other than 'meds will be given at mealtimes and bedtime'. There's a policy now, and a multi-step procedure with the 5 rights and 3 checks built in. It's good to know my mistake did some good in the long run, but it was still terrible.

The second was about 5 weeks ago during clinicals. I left 3 used insulin syringes on a resident's bedside table. The needles were sheathed, a staff member found them, no one was adversely affected, but I thought I was going to puke on my instructor's shoes when she brought it to my attention. THEN she had to call the school to have the applicable policy and discipline forms faxed to the clinical site. For about an hour I was sure my nursing career was over. It turns out that, since there was no exposure or injury (and I was able to come up with a plan to avoid doing that again), I just had to sign a form saying I'd been counseled about unsafe practice. :smackingf

[johnst10]

Not my fault, all my problem!

I had gone to the ER with the classic Kidney Stone Dance. The first day they sent me home. I barffed all night, called the ER like the instructions said, they said to call my PCP when the office opened up 3 hours later. Told DH my temp was 103... My husband insisted on taking me to the ER again. Well, I knew something was wrong when I saw the blood culture tubes coming. (also had spontanious diarrhea on the way to the commode. The nurse looked at DH like he was going to clean me up. I don't think so). Then they commented about my BP. Next thing I knew I was on Dopamine and getting a fluid bolus.

Got sent to OR holding to have a tube to open my right ureter, nasty stone. (klebseilla can do ugly things to a person's blood stream). The CRNA came up and asked if I needed pain med, Yeah, I did!!! I only had one peripheral line. He pushed the 2mg of morphine in 1 ml fluid rapidly pushing the dopamine ahead of it. OMG. My head split in 2, my heart left my chest it was pounding so hard, my lungs felt like they wouldn't work. I thought I was dying. I couldn't really even talk I was so scared.

IN the ICU I watched the monitor to see if SBP was above 90, called the nurse every time and asked if we could turn it off because I had a wicked HA.

I NEVER give a pt dopamine without telling them to be sure to let me know if they have the above side effects. Why I never got a centeral line is another story.

[AriesLPN]

Am I in trouble?

It's been bugging me and I just need to get it off my chest.. I work on a medicine floor and had a 90+ yrs old pt on a 1:1 observation for s/p fall at home. The pt became restless, confused and trying to climb out of bed in the middle of the night. I had to call the doctor to see if a medication can be ordered to help calm her down. The doctor ordered a one time does of Haldol 1mg PO which I administered. Nevertheless, the pt still remained restless and confused throughout the night until the morning. The 1:1 was there with her the whole time to prevent falls. That day, when the family member found out Haldol was given, she was so frustrated and complained to the head of the hospital. Now, I'm concerned she might take this to a different level (lawsuit or something) The patient was never again ordered Haldol and was dc'd home days later.

Should I be worried? What is the worst that can happen? Can I lose my license over this? So scared and convinced this family member is out to get me =(

[talaxandra]

Unless there was a notation that the family opposed Haldol administration already in the file I think you are fine. It was an appropriate dose given in an appropriate setting, prescribed by an appropriate person.

[Aurora77]

I'm so glad I found this thread. I made a horribly stupid mistake today in clinicals. My pt had PRN topical meds in her MAR, so I noted them, looked them up, and was ready to give as needed. Unfortunately, several pages past that were BID orders for these same meds. They were BID and PRN. I was having a good day at clinicals and then my instructor caught that. I feel horrible. Fortunately, I was able to give them, but at the same time I'm so freaked out. All I can think is what if my delaying getting them hurt my pt? Rationally I know that in the scheme of things, she's probably going to be fine, but I feel so awful about it. The last thing I want to do as a nurse is to hurt my patients through my mistakes.

Now I'm just hoping everything works out OK with my pt and that I don't get kicked out of school for making such a stupid mistake. It's a comfort to know I'm not alone in this. I can definitely say I will be busting my butt to make sure nothing like this happens again.