med errors

glascow · Jul 7, 2003

When I realized I made my first med error, I was sooooooooo freaked out! I wrote it up, my nurse manager told me not to worry about it and tore it up. That was over 10 yrs ago.

No harm came to the patient. After discussing the situation with experienced nurses I respected, this is the lesson I came away with.

Any nurse who says they never made a med error is a liar!

It is an awful feeling when you discover you have made, or almost made a med error. What scares me more is how many nurses (including myself) don't even realize they have made an error?

Rapheal · Jul 7, 2003

Jeez cotjockey-how was that med error your fault? If it is not documented-how could you know?

2banurse · Jul 10, 2003

Cotjockey, I agree with Raphael...how can they blame you for that med error. If you didn't give the medication, you would probably been screwed there too. At least you documented when you gave the med.

Kris

susanmary · Jul 10, 2003

cotjockey -- both the doctor and your nurse manager wrote YOU up? Am I missing something? Your charge nurse gave a narcotic on YOUR patient, did not chart this or inform you of this -- and YOU are written up???? Do you have a pyxis -- were you able to see the last time/date that this medication was removed from the pyxis? The incident report should not have placed blame on you --although her intentions were to help you/the patient -- she omitted to chart a med/narcotic -- the incident report should not have placed blame on you -- it should have focused on the uncharted (but given) narcotic.

flashpoint · Jul 10, 2003

Yes, we have Pyxis and I didn't bother to look there to see when the last med had been given...hence, my fault according to my nurse manager. My nurse manager tends to fly off the handle about a lot of things...chews butt and then asks questions...LOL. Not really a big deal to me...the incident report clearly states that the 1000 med was not documented, but still, I'm the one who got the blame...

rileygrl11, BSN, RN · Jul 11, 2003

I, too, hung the wrong med on the wrong pt. Fortunately, it was an antibiotic that the pt had been dc'd off of earlier that day. And the person who found it was the pt's relative who happened to be a PCT on another floor. I felt soooo embarrased and stupid! :eek: The PCT actually told me about it and requested not to tell the pt "since no harm was done." I ended up doing an incident report on myself and my shift manager was very cool about it. After checking with other nurses, everyone of them had admitted they made a med error or two in their career. What was helpful was that someone told me that a "bad" nurse would not of felt so bad but a "good" nurse would be upset with themselves.

ktwlpn, LPN · Jul 15, 2003

How DO you properly document a med error? Had a whopper at my facility yesterday-a nurse gave a handful of meds to the wrong pt....I can only say that the patient became symptomatic and had to be sent out FAST and was admitted...I am not in today so I don't know the patient's current condition....I looked up each med the pt received-the onset of action,peak etc and sure enough-as predicted-the pt's condition stared to spiral d-o-w-n exactly 2 and a half hours later.....I did not give the meds but I was responsible for taking the appropriate action-notifying the supe,monitoring the pt's condition -we tried to encourage fluids,took signs,etc and so on and I did all of the documentation-the incident reports and extensive nursing notes.....Here's the question I have today-do you document in your nurse's note the meds and dosage the pt received in error? Should that info be in the legal record?I am really freaking now-I am sure I'll be crucified tomorrow if I did anything wrong-even though I did not give the meds......I was totally honest with the family-per the DON...I did NOT sleep well last night......I hope the patient is allright.....This is the most serious error I have ever been involved in and I will admit I am scared.......

live4today, RN · Jul 15, 2003

I have made a few med errors in my time, but who hasn't? And...if they haven't as yet...they will.

If I make a med error, I write up my own incident report. I've also had to write incident reports on med errors made by others.

I agree that a solution to this problem could be better staffing, and less stress on the staff. :nurse:

Rapheal · Jul 18, 2003

ktwlpn,

Can you give us an update?

ktwlpn, LPN · Jul 18, 2003

The resident has done well and returned from the hospital 2 days later.I had spoken to thefamily twice on the day of the incident and was very honest and apologetic without making excuses and they were fine.The next day the doc came in ranting and raving about how upset the family is and how he did all he can with them and we had better talk to them,etc.So-we call them again when the resident returned-the other nurse made that call and the family was fine.We have no idea what the doc really said to these people-other then neglecting to tell them that when the incident happened initially he blew us off-no orders,nothing-hung up the phone....Later when the resident became symptomatic(circling the drain FAST) we could not reach the doc so we called 911.....We read in the hospital h and p a different story...The doc claimed that he had the resident sent right out for monitoring after the med error,etc....He likes to cya and will put a nurse in the hot seat with a family in a heart beat-we really have to be careful .....The doc blew a bit of smoke-ranted and raved in the medical staff meeting but nothing came of it because the other doc's stood up for the nurse....Bottom line-the resident is just fine-Thankfully.....It was a bad day....I am so glad it worked out-the other nurse was devastated and I believe never would have come back if the outcome had been bad....