Med errors

Nurses General Nursing


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68 Posts

Originally posted by bedpan

i am just a student and am maybe misunderstanding what is being said but - I was under the impression that it was only the state board who could suspend or take away your liscense and during that time you were not allowed to work period?

How did anyone get "demoted to aide" and who did that?

you are under the right impression bedpan. only the BON in your state, after very careful review, can suspend your license.

Specializes in Oncology/Haemetology/HIV.

Everyone makes mistakes and current theory indicates that for most, there not be punitive action taken - that would keep people from being honest about them and encourage them to cover up for them.


At last job as nonagency, the boss had a few favorites. One of them, a nurse with at least 20 years of experience, kept making mistakes...and making mistakes....and making mistakes....and making mistakes. The narc counts were off repeatedly and we would frequently find the wrong IVPB hanging on patients. The boss kept her on.

Finally, she finally made such a horribly wrong mistake that had to be reported as a sentinal event. She disappeared from staffing. "Needed some extended family time" was the line.

If it had been one of the people on the boss' Bulldust list - would it have been so nicely worded or taken so long to occur? Somehow I doubt it.


6,011 Posts


Re: grains.......first of all the doc who wrote it that way ought to know better. Old bats like me understand (sometimes) the old apothecary system...BUT modern medicine orders should be written in a standard METRIC system.

Specializes in Oncology/Haemetology/HIV.

Anyone for drams or minims

CseMgr1, ASN, RN

1,287 Posts

Specializes in Case Management, Home Health, UM.
Originally posted by sympathoadrenal

Ok, CseMgr1-

1/64 gr is a half of 1/32 gr.

If it's easier to understand, 1 grain equals to 0.0648 gram and

approx. 1/32 gr = 2 mg and 1/64 gr = 1 mg.

Anyway, 1/32 + 1/32 = 2/32 = 1/16 (not 1/64!!!)

Yes, it is scary. We better caliculate correctly or sorry.

Back in those days, a normal dose of Dilaudid was one amp (gr. 1/32). Her doc had ordered 1/2 that doseage (gr.1/64). The nurse who gave her the Dilaudid got confused, and gave her two amps, Instead. It was clearly a mental error on her part.

Sorry for the confusion.:)


94 Posts

The license to practice nursing comes from the state board of Nursing. After successfully completing the NCLEX and receiving their license, the nurse can then use this license to earn a living.

If you (and about 99% of us do) voluntarily allow yourself to become employed by an agency or large instituition, you have willfully allowed that agency to hand you all sorts of crap, including unsafe workplace practices, short-staffing and other distractors that set the stage for medication and treatment errors to occur. Only within nursing are people so stupid as to have their power and authority usurped!

In reality, you are only responsible for yourself, your patients and to the state BON. Hospitals can and do make up their own rules, and can decide who or when to call the state BON to report you. Some hospitals will say that "a medication error is a medication error. One strike and you're out!" Administrators can't understand that milk of magnesia is handled differently and with different potential harm than methotrexate.

Too big a deal is made of medication errors when the overall workflow design is what should be evaluated and redone.

What about errors committed by pharmacy and the MD's? The MD failed to write the correct drug, dosage, frequency for the correct patient? The nurse is expected to intercept these errors (and does everyday) and have them corrected so that they aren't a "real" error. The pharmacy sends the wrong drug to the floor because of poor handwriting and/or illiteracy? the nurse has to rewrite the medication order in plain block letters so that he pharmacist might understand it.

Any way you look at it, the nurse is screwed.

Did you know that you can develop your own standards for when to call the state BON to report a supervisor or DON, who, like you, have the same license. Nurses employed by hospitals are set up for failure no matter how you look at it.

Another thought. The legal precedent was set in the state of CO

several years ago. Nurse involved in a medication error were tried in CRIMINAL court for this offense. As a nurse, you are the only licensed professional that can be tried as a criminal, rather than in civil court (like MD's, pharmacists).

Just a few of my thoughts on med errors. Edward, IL


586 Posts

I hate working with grains...had a doctor order x gr for tylenol. Took me forever to figure out what it was, and then had to go to another nurse to make sure the dosage was correct.


814 Posts

The grains, oh the grains...... Here is Momma's quick and easy way to figure out grains.

1/32 vs 1/64

take 1 divide by 32 and multiply by 60 to get mg 1.875 mg

take 1 divide by 64 and muliply by 60 to get mg 0.937 mg

and I think (correct me if I'm wrong) that x grain for tylenol is

1 grain = 60 mg. So x grain is 10x60mg=600 mg. tylenol right?

anyways--- if it says grain - it's gonna be a pain.

Specializes in MICU, neuro, orthotrauma.

x = 10

Jay Levan

154 Posts

:confused: I am sorry but I have to tell you that, from your post (Trixie) that it appears that you are focused on the "Mystery" of just what exactly will happen to one if one makes to many mistakes, instead of directing your focus to the real problem, the making of errors period. To be sure there are many reasons why mistakes are made and there are as many different ways that they are handled by Nursing administration, which also depends a lot on the current staffing patterns in your particular hospital, LTC facility, etc. etc. If there is any way I can help to change your focus in the proper direction, I would be happy to do so. I will not criticize, but rather relate how I go about Med. passes, beyond the five rights, I always go over each patients meds with them before I give them, and I treat each as though they are my most precious loved one, (Mother, Sister, Brother, Father, Aunt, Uncle, etc. etc.) I rarely have to give meds, so I have become real RUSTY, consequently it takes me a lot longer to pass meds on my section, however it is worth the extra time to make sure I do not harm any of my "relatives" :D Get the Picture?? Jay

Chaya, ASN, RN

932 Posts

Specializes in Rehab, Med Surg, Home Care.


We learned one grain equals 65 mg.

So for Tylenol, 5 grains + 325 mg. + one tablet.


33 Posts

I have also seen med errors committed by seasoned nurses like giving regular coverage for a FSBS when the order clearly called for another type of insulin. When I brought this to the NM attention she snapped, "well, did YOU see it????" I told her, here it is, all signed off with "R" clearly written under the insulin name. Nothing at all happened to any of them. Another time I asked about an unsigned one time order and was severely reprimanded. So it's up to the management, bottom line.

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