med errors

[zaleah]

Very interesting thread going in the general discussion, a med error caused a death and the nurse that hung the med is looking for support or others...

she/he states that 7,000 med errors occur every year....I think it is higher then this.

Let's offer some support----

What is your worst med error?

Have you witnessed a med error by a doc?

I posted this in the general discussion--this is my nightmare...

I too have made errors. In 15 years I have made 2 significant (sp) errors that were potentially deadly. The first actually ended up benifitting the patient. I work ED and was fighting with the internal med team to intubate and sedate a very sick septic pt, they did not want to as he was 'not an ICU candidate', I got mad and finally said "you have got to at least sedate him--he is going to fall off the bed and he is ripping his lines out." They ordered 20mg of Valium (hx of etoh abuse) I thought they meant IV, they meant IM. I gave 10mg, waited 10 min and gave the 2nd 10 mg. As the team rounded on the pt he resp arrested. The attending was not pleased, they were forced to intubate, the ICU guy was livid, but the man got appropriate care, I just got the greif.

The second was not so good for the pt. A very anxious mother and daughter team, the Mom had a picc line for chemo--they were harrassing us all day for minor stuff, and I cannot even remember why she was there, "she is near someone coughing", "the sheets have a spot", "was this room cleaned properly", etc..... Mom finally got her get out of the ED card and I went to D/C her picc and flush her line so she could go.

I grabbed the heparin and a 10cc syringe and ran in so I could get rid of these pains in the )&*&(. As I slammed the syringe full of fluid in, I realized what I had just done---flushed the line with 10cc of 10,000u/ml of heparin. I was freaked.

The doc on was surpizingly wonderful--he has a reputation of not caring about anyone but himself, but let me tell you, he sure went to bat for me. He called hemetology to find out if we should give the antidote for heparin (that my brain cells are blanking on right now cause we never use it) and they said no, just moniter as there are too many side effects. I went to the Mom and Daughter team and explained everything and apologized. Lots of tears, and the daughter went nuts--unitl she realized Mom was now going to be admitted for observation. I followed the pt, and her clotting times did not come down for over 5 days--they should have been down the next day!!! I lived on egg shells!!

Mistakes happen, we are busy ----WE ARE HUMAN!!!!!!!!!!!!! Is your work supporting you, are your collgues and manager behind you? What about the docs? Is there an internal support phone line?

You are right we need a support group--if either of those pts died because of me I would be freaked out, but looking back on my 2 near misses I realize there are system errors that also occured and my shoulders need not be that broad. NOR DO YOURS. You are a good nurse, and as everyone else has said--think of the good you have done.

Could you start a thread "What is you worst med error?" some version of a support group? it is all annonymous right? Are we not supposed to be learning rather then blaming?

If anyone can offer support here is the link for Julie who started the main thread...

https://allnurses.com/forums/f8/7000-fatal-med-errors-last-year-where-theses-nurses-171356-new-post.html

this is a good one... it is about supporting with honesty, not hiding errors and learning from them.

[JazzyRN]

interesting thread, we have all made them, but how many are willing to admit it?

personally ive made 2 med errors in my nursing career. the 1st one was as a new grad on orientation, i think it was my 2nd week on the floor. I had 2 pts getting pain meds, one was getting tylenol with codeine and the other was on percocet for pain. i gave the tylenol with codeine to the pt that was supposed to get percocet. I didnt realize it until I went to give the other pt the wrong painkiller and he pointed out to me that the pill was a different color. it was then i realized the mistake i made. i reported it, everyone was supportive, no adverse effects. my 2nd med error was giving novolin insulin instead of novolog. the pts blood sugar was higher than it should have been, since i gave a long acting insulin instead of the short. the insulin was "double checked" by another nurse, but you know how that goes when people are busy. both incidents definitly made me a better nurse and i see and implement ways i could have done things better to prevent that from happening again.

[LoriAlabamaRN]

In the two years since I've been out of school, I've made one med error (that I know of). I was working night shift, taking orders off of charts. One order was messily written but seemed to obviously say "Desyrel". I had another nurse check it to make sure, and that's what she read it as also. I checked the med book to make sure that it was a safe dosage (since I still had a nagging worry about it) and it was, so I gave it. Come to find out the next night that the order was for Seroquel, and I was SO upset. If he had been allergic to the Desyrel, I could have killed him. That's why I say that but for the grace of God, I could be where she is now.

[nursebrandie28, BSN, RN]

I made a potentially deadly med error right out of school...i hung a magnesium rider on a pt who was supposed to get a K rider and the pt who was suppose to the mag rider did not get her dose....luckily no adverse affects however my nurse manager hung me up to dry...she said that i was an awful nurse and another mistake and i would be fired.....i was in tears....i was the talk of the whole hospital....my response was if they didnt give me 12 pts on a tele floor...maybe med errors would not happen so much

[LauraF, RN, ASN, CNA, LPN, RN]

I too had a med error right out of school. I had not even taken LPN boards yet. I worked at a home for children. They had no id bands. I had two girls on anticonvulsants. One on tegretol liquid the other on valproic acid. I got the two girls confused. The one that received valproic acid was much smaller build so she got a lot. They did liver panel, and did q hour vitals. Nothing major happened, but it really made me question was I going into the right profession. And I always worry now at my new job, I don't know these people, they have no id's. I hope I am giving the right meds to the right people. But...since my med error, I will sit and wait for a CNA to double check the patients name before adminstering medications to the patient. Because some of those people are so far out there, they just answer yes or no to everything.

[Carlos Casteneda]

dont know if this entirely fits this thread but a junior nurse has just asked if it would be acceptable to resuscitate a patient on a DNAR if the cause of their arrest was due to a nurses drug error i cant think through the consequences at present what do people think

[garciadiego]

I think this is a useful thread....I wonder why more have not participated? myself included.

[garciadiego]

I realize this is a very old thread, but timely.

I was reading zaleah's post...is she saying she gave 100,000 units of heparin?...10cc syringe of heparin, 10,000units/ml. Isn't that alot of heparin?

[Larry77, RN]

I realize this is a very old thread, but timely.

I was reading zaleah's post...is she saying she gave 100,000 units of heparin?...10cc syringe of heparin, 10,000units/ml. Isn't that alot of heparin?

We normally give 10ml's of 100units/1ml of heparin in this case, so yes is a lot...

I'm not sure about the DNR question but it would probably be a case by case question depending on how ill the patient is. If the patient is in hospice and was a DNR no matter what maybe not but if they were a DNR but probably had months or years to live I would say yes...depends on the situation though...too many variables (type of med error, condition of pt etc etc).

[Guest219794]

Since most med errors do not cause harm, I am concvnced that they happen frequently without anybody knowing. Other than timing errors, i don't know of any that I have made, but I am sure that I have.

FWIW, In my 5 years nursing, I have caught several MD med errors. We double check them, but nobody double checks us.

hherrn

[Debbie Jones]

I have been suffering a med error nightmare since 2006 that went on my criminal back ground check as a CRIME.