Published Nov 2, 2001
Anybody out there have any stories or situations to tell concerning medication errors to serve as a warning for us less experienced (or seasoned) nurses?
I don't know if this qualifies or not, but here goes anyway.
Last weekend, another agency nurse (from a competing agency) came to the facility where I work the most, and worked a day shift.
She was an older RN, and had (supposedly) 20 years experience in a hospital, and had been working with this agency for a while.
Anyhow, she came in, with a few hours from the previous day as orientation, and passed meds and did treatments.
When I came in the next morning, I found the staff nurse in a much more welcoming mood to me than she has ever been.
When I asked her what was up, she told me some very disturbing scenarios from the day before.
The agency nurse had been assigned to a patient who has both nebulizer and inhaler rx, and the inhaler was given in lieu of the nebulizer.
When the staff nurse questioned why the agency nurse was carrying the inhaler, and the patient had asked for the nebs, the agency nurse stated, "There is a difference????"
Well, the staff nurse was really upset about this.
Later in the shift, the agency nurse asked the staff nurse where a particular medication was kept. We use all unit dose, so the staff nurse stated that the med was most likely in the patient's drawer. When the agency nurse said there wasn't any in the drawer, the staff nurse looked, and the med WAS in the drawer, just in the generic form. It was SUDAFED. The staff nurse then asked the agency nurse if she had checked the med book for the correct names, and the agency nurse said she couldn't find the med book. It is in PLAIN sight in the med cart.
When I started to pass meds Sunday morning, I found 15 instances where there either were meds missing from the drawer for the next shifts, or there were extras in the drawer. The meds are replenished q 3 days, and there are almost ALWAYS no mistakes in the drawers, because our pharmacy is really good.
So I pointed this out to the staff nurse, (my RN) and she said, "I am not in the least bit surprised." Apparently the agency nurse was one who had an attitude that, "I am right, and don't NEED to check the med book, etc..."
I was really surprised myself, because I am SUPER careful when I go to a new facility, and even after I have been there a while, cause the orders change so quickly.
WHat happened to the old "check 3 times" policy?
This nurse was so sure of herself, and made mistake after mistake. She left old Nitro patches on the patients, and I found two of them on most of the patients.
She also didn't do treatments that she had signed off, and she was marking the meds as given when it was clear she hadn't given them.
I just don't know what to think about the carelessness of the agency nurse.
I know she will be getting some sort of discipline from her agency, and she certainly won't be coming back to this facility.
I just don't get this kind of behavior. And I am sure that this isn't an isolated incident. Nobody makes this many mistakes in one shift accidentally.
Even the nurses that I know who have been working at this facility for a long time double check themselves all the time. And I never hesitate to check a med in the med book if I am the least bit unsure about it. I use my med book every day.
We as nurses should NEVER get so sure of ourselves that we aren't willing to recheck something. The smallest and most insignificant mistake could cost someone their life.
I have a med error story of my own. I was new and had prepared my meds in cups to go into two seclusion rooms (on psych unit) with patients who needed a security escort to get meds and meals. Security was called and we were ready to go into the patient's rooms.
I gave pt # 1 his meds and dinner and we left and locked the door. We went into pt #2's room and I went to give her the medications when I noticed something wrong. I had given pt #1, pt #2's medications. The only reason I noticed was that I recognized the green haldol that was in the cup and I knew that pt #2 had previously gone into resp arrest when given haldol before.
I was able to go and get her the proper meds and pt #1 had no adverse effects from receiving wrong meds. Of course I reported my med error to the doc and the whole staff knew I had made a med error but I was just so happy that I did not send this really nice (but terribly psychotic) pt #2 into resp arrest.
Errors are made sometimes but it gets better as you gain experience. Knowing which pills are what color and following your hospital's checking system really does help to prevent errors. Never be afraid to look up a med that you are unfamiliar with. Keep the med book close. After you look them up a few times, you won't have to do it again. Oh, and don't be afraid to admit to med errors. Hospitals have preprinted med error paperwork for a reason you know, it is not as rare as we would like. You will always sleep better knowing that you were honest.
What is it they say? "There are two kinds of nurses. Those who made med errors and those who will make med errors..." What I say is, "Safety first because second is too late." I'll agree with Marla. Never be so sure of yourself or so over confident that you slip up because eventually, it will cost someone their life.
I'll tell you my experience with a med error that I made...
Pt. asked for a "sleeping pill." He had a restoril 30 mg @ HS order. OK. I went to the narc box pulled out two 15 mg caps. (we were out of 30 mg caps) The pt. sat in his w/c outside the med room waiting for the med. I locked the box, handed him the restoril, he took it and went to bed. I handed the other nurse I was working with the narc keys and along came another pt and asked me to help him snap his pj bottoms so I did. Then the call bell began ringing and I answered it and took care of his problem. After that it was report time. The other nurse had counted the narcs prior to me pulling the restoril and signed the narc book which I hadn't a clue. Since the midnight nurse called out, we waited for our relief nurse to show up. The other nurse said after about 20 min,"Why don't you give me your report and go. There's no sense two of us waiting for the relief." So I did and left. The relief nurse came. Never worked our unit before went to count the narcotics and two restoril 15mg caps were missing. WELL, that was it. She called the super, the super called the police. She never checked the PRN med sheet of which I charted that I gave restoril to. Could have even asked the pt if he received his sleeping pills. (It was noted in my report that pt."X" received restoril 30 mg) She could have called me at home and asked. But someone figured out that I gave restoril to a pt because when I went in the next day, I had to make out an incident report, a med error report and a police report. The relief nurse was only doing her job by calling the super. I was wrong for not charting on the narcotic sheet. I should have signed then gave. I gave and didn't sign due to getting sidetracked. To this day whenever I sign out a narcotic, I always think of those reports I had to fill out! Be careful to what you're doing. It could cost you your license! Luckily I still have mine...
You made a paperwork error, not a med error. I would hate to work where you work. I always alway always miss at least one narc on the narc sheet (even though it is marked in the MAR as given). When you give the number of narcs we do, it is just a fact of life on my unit. We make a joke out of it cuz I always miss a narc on the narc sheet. But, my coworkers and I both look at the MAR to see who is on that med and who got it today. We have always found the paperwork error. I can't believe that the counting nurses did not do that and that the super did not suggest that or do it herself. Calling the police over two Restoril??? And the police came??? You must work in the prison right?
I guess if that happened to me, I would never miss another narc count again. You have much more patience than I do. Where do police come for two pills?
Many hospitals have 2 nurses check all insulin doses to avoid errors. If I were a new nurse, and even now I'll have someone check it especially with a new patient.
Always remember and actively practice your 5 Rights and you'll do fine.
"...routine coagulation tests such as Prothrombin Time (PT) and Activated Partial Thromboplastin Time (aPTT) are relatively insensitive measures of Lovenox Injection activity and, therefore, unsuitable for monitoring." This is from the package insert for Lovenox. However, it is correct that platelet count should be monitored for thrombocytopenia.
PT/INR is used to monitor Coumadin. aPTT is used to monitor heparin.
VickyRN, MSN, DNP, RN
ALMOST had a med-error with Librium. Confused pt with PRN IV Librium orders. Had very rarely if ever given this drug IV before. Diluent in ampule to break and mix with powder to draw up in syringe. Turns out this diluent is for IM USE ONLY!!! No significant warning, only small print on insert, "diluent for IM use only." NEARLY gave this to a pt IV; another nurse came along PROVIDENTIALLY just before I was about to administer the Librium IV and stopped me. I was literally shaking at how close I came to harming this pt. Medication errors are where most nurses get in trouble. I can't stress it enough--always take the time to be careful--check, check and recheck. If you're not familiar with a medication, confer with the pharmacist, another experienced nurse, and a good drug book. You can't allow yourself to be rushed or distracted. Pt's lives are on the line.
Another common source of error: IV piggybacks (antibiotics and drips). It always pays to check and recheck that the bag is activated and infusing. Take the time to recheck when you come back to pt's room that bag is emptying properly. There was a situation on our cardiac floor, where a bag of cardizem was hung on a pt and the cardizem NEVER ACTIVATED!!! All that was going in all shift long was NS... Pt was in a-fib and later coded. Easy to overlook something like this when you're running behind and stressed out. However, much too important to overlook...
moonshadeau, ADN, BSN, MSN, RN, APN, NP, CNS
Had a situation where I had a very involved patient (you know the kind with tubes coming out of every end,MRSA too). Someone prior to me had read the order to change Senekot to PRN. The patient also happened to be on Sinemet at the same time. Whomever d/c'd the drug, d/c'd the wrong drug. The Sinemet was missed for two doses. Needless to say the doc was not too happy.
The biggest lawsuit and malpractice payment my hospital ever faced was due to a horrific med-error that resulted in a tragic patient death. This occurred years ago in the L & D unit and since then, our facility has made changes to help insure this type of error never happens again.
A nurse in the L & D opened a 1000cc bag of LR and mixed 40 grams of mag in the bag. Well, she got distracted and left the bag of LR on top of the med cart WITHOUT a medication label. The nurse apparently forgot about the bag and went off the floor to lunch with the unlabeled bag still on top of the cart. Another nurse came along, saw the bag, and decided to use it for her pt (it never occurred to her that any medication had been added). This second nurse had a pt who had just finished delivery of the placenta, her uterus was boggy, and needed some pitocin. The second nurse then added 20mg of pit into the bag of LR and hung it on gravity "wide open" on the pt (as was the custom in this unit after the pt had delivered to help stop postpartum bleeding). The pt died shortly afterwards, both nurses lost their licenses and a newborn was left motherless.
Now, only the pharmacy can mix mag or K+ for infusion. The lesson here is to NEVER use an opened bag of IV fluid--you never know what may have been added to the bag.
My pet peeve are those asinine doctor's orders "Resume home medications" or something to that effect. This sort of scenario really compromised a pt (and got a nurse in really hot water) in a small facility in which I worked years ago. The particular doctor involved was NOTORIOUS for prescribing TONS of medications for ALL of his patients (the MARS were a nightmare--3 or 4 pages each...). Well, the nurse receiving a new admit was confronted with the order "home medications...." which she dutifully tried to sort out and write as a "voice order" from the doc. She was already stressed out and harried that day by her pt load. Turns out, she just happened to leave off one of the pt's meds (out of 20 or so that he was on)... Synthroid!!! The error was never caught, and after awhile, the pt went into a myexodema coma!!! Of course, the nurse caught the flack, not the doctor who was too lazy to write his orders in the first place.
So, whenever I encounter one of those types of orders (whether admitting or discharging a pt), I simply refuse, telling the doc "prescribing medications is outside of my scope of practice." I then tell the doc it is HIS call to order each med he wants.
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