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!
A memorable error happened about a week after I hit the floor as a new nurse.
After I gave the patient his medications, I went back through his MAR to make sure I signed everything off. I noticed that there were two entries for Procardia XL: 30mg and 60mg. It turned out that the doctor had increased the dose from 30mg to 60mg, but whoever took off the order forgot to change it in the MAR...so I ended up giving the patient both doses, 90mg in total.
The sad part was that when I pull medications, I usually say what I'm pulling and the dose, both for the patient's benefit as well as to double-check myself...and neither he nor I noticed I said Procardia twice.
There was a happy ending though: the patient's blood pressure was finally WNL for the first time since he was admitted two weeks earlier. So we called the doctor, who wrote a one-time order for the extra dose I gave, then rewrote the order to make it 90mg. It ended up going up to 120mg before the patient was discharged.
Aurora77, I doubt that your pt was hurt by a couple meds being late. You didn't give anything that she doesn't normally get and she got her meds eventually. There are going to be times in the hospital when you're late just b/c you're so crazy busy. And your pt will survive. It's all a learning experience. Don't beat yourself up about it. :hug:
This thread is a God-send. I was just moping about a med error myself.
I got QTC'ed about a med error that happened the Thursday night before Easter. Found out about it yesterday morning. I started Heparin for the 2nd time ever, misread the order and ran it at 2500 units an hour. It felt weird to me at the time, but I got my charge nurse to cosign for me, and she never said anything about it. So, as a new nurse, I thought that, well, it must be okay and my instincts must be wrong, so I ran it. I even used the proper program in the programmable IV pumps for the first time ever, and it didn't catch me either. So I thought that it was fine. Pt was post cath and his groin popped for the day nurse. My DON said that he was fine, but I feel horrible. I remember double and triple checking that order and I still got it wrong.
Then I further embarrassed myself when I came into see her this morning after my shift ended by crying when I signed my write-up sheet. Med errors like that scare the crap out of me and I tried to be so careful. I learned from it, but it really upset me. I had a full team the day of the error, a pt actively dying, and another in contact isolation who was a total, was unresponsive, and who was having what looked to be seizures (first time I'd had a pt with seizures). I guess I was distracted that night. I will learn from the experience and that error will never happen again (I am slightly OCD, esp. when it comes to my pt's safety), but I'm very upset that it happened it the first place. I don't like my pt's being hurt b/c of me. I'm just glad the dayshift charge and the day nurse caught it in time.
Thanks for sharing your stories. I just had my med error yesterday. I gave a med that was discontinued and patient was allergic to it. Notified the charge RN and the MD. NO harm done with the patient, THANK GOD, but I really felt bad making the error! I just hope I'll get over with it pretty soon.
I feel really thankful for you sharing your stories. Just made my first med error yesterday. I realized I forgot to give a patient a dose of keflex. It's my first (and hopefully last) error, and i can't help feeling very stressed about it. However, reading all the stories here has given me a little hope.
Meriwhen, ASN, BSN, MSN, RN
4 Articles; 7,907 Posts
A memorable error happened about a week after I hit the floor as a new nurse.
After I gave the patient his medications, I went back through his MAR to make sure I signed everything off. I noticed that there were two entries for Procardia XL: 30mg and 60mg. It turned out that the doctor had increased the dose from 30mg to 60mg, but whoever took off the order forgot to change it in the MAR...so I ended up giving the patient both doses, 90mg in total.
The sad part was that when I pull medications, I usually say what I'm pulling and the dose, both for the patient's benefit as well as to double-check myself...and neither he nor I noticed I said Procardia twice.
There was a happy ending though: the patient's blood pressure was finally WNL for the first time since he was admitted two weeks earlier. So we called the doctor, who wrote a one-time order for the extra dose I gave, then rewrote the order to make it 90mg. It ended up going up to 120mg before the patient was discharged.