medical error injection

Nurses Safety

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Hello I am new here and sorta new in the field.. I was supposed to give a patient an injection and gave a PPD medication instead of the flu vaccine and then i didnt realize it again on another patient! Both patients had bigger arms..but only one i was aware when the patient was still in the office! The dr said they she will be ok. So i reported one instead of both. my friends say she should be ok.. but i still have a bad feeling, besides the fact i messed up.

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Specializes in Psych ICU, addictions.

I can't believe you mistook tuberculin for influenza vaccine and/or mistook a TB syringe for an IM needle...ok, I can kind of see the needle one happening, since they do use a small gauge needle for a deltoid injection. But still...

Yet another graphic reminder why it's important to practice the rights of medication (5, 6, 10, whatever number you roll with) and check meds before AND after administering them.

Ok, deep breath. You made the mistakes, you can't undo them. You're human. You're not the first nurse to make a med error and won't be the last...the important thing is to learn from this and not repeat it.

I'd fess up about the other patient. Yes, it's 99% likely that the other patient will be fine...but what are you going to do if this patient happens to be one of the 1%? Better to be honest and take responsibility upfront.

And be more vigilant when pulling and administering meds. Take your time--there's no reason to rush. Double and triple check. Never draw up a med into a needle and leave the needle unlabeled; you risk forgetting what you drew up. Also, do not administer meds that another nurse has pulled because they could have made a mistake.

Beat yourself up for the rest of the day, then learn from it and put it behind you.

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Specializes in Adult Internal Medicine.

You absolutely have to be honest about the other patient.

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So one of the people thinks they got a flu vaccine when they didn't?

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Specializes in Adult Internal Medicine.
So one of the people thinks they got a flu vaccine when they didn't?

It's ok because her friend told her she'd probably be ok.

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Specializes in Pediatrics, Emergency, Trauma.

I'm confused...did you give the PPD IM and the flu vaccine intradermally???

I'm just wondering....

Also, why would you omit one other pt??? What if something happens to the other pt by giving the wrong route??? If they would've been notified, they would be able to look for other issue they may arise; you are not doing the other patient any favors if an adverse reaction occurs, nor by being accountable for a potential issue.

I understand you feel bad, however, it's best to have been upfront about BOTH errors; you still have time to tell. :yes:

I don't know how worse you will feel if the patient who was not aware if the error has a complication...

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Um, Didnt say i used a tb needle. i used an IM NEEDLE 25 REGULAR NEEDLE. I JUST mistook the medication.

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Specializes in Critical Care, Education.

OK - 2 major mess-ups here. 1) two patients who did not receive the flu vaccine that they were supposed to have & 2) IM injection of PPD. Both patients need to be fully informed about the mistake & follow-up care needed. Obviously, they need to get that flu vaccine. What are the potential consequences of receiving PPD intramuscularly - especially if OP injected the same volume as flu vaccine rather than the teeny amount used for intradermal?

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Specializes in Emergency, Telemetry, Transplant.

You definitely must report both of them. In addition to the reasons mentioned above: suppose that there is something confusing about the labeling on the vials. How are the manufacturers of the vials going to know that they have a problem? If people giving the shots report that there is a problem. It was a med error. Unfortunately, they happen. Now do the right thing and report it.

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Specializes in Pediatrics, Emergency, Trauma.
Um Didnt say i used a tb needle. i used an IM NEEDLE 25 REGULAR NEEDLE. I JUST mistook the medication.[/quote']

Um, this is what YOU said in your original post:

Hello I am new here and sorta new in the field.. I was supposed to give a patient an injection and gave a PPD medication instead of the flu vaccine and then i didnt realize it again on another patient! Both patients had bigger arms..but only one i was aware when the patient was still in the office! The dr said they she will be ok. So i reported one instead of both. my friends say she should be ok.. but i still have a bad feeling besides the fact i messed up.[/quote']

And this is what I wrote:

I'm confused...did you give the PPD IM and the flu vaccine intradermally??? I'm just wondering.... Also why would you omit one other pt??? What if something happens to the other pt by giving the wrong route??? If they would've been notified, they would be able to look for other issue they may arise; you are not doing the other patient any favors if an adverse reaction occurs, nor by being accountable for a potential issue. I understand you feel bad, however, it's best to have been upfront about BOTH errors; you still have time to tell. :yes: I don't know how worse you will feel if the patient who was not aware if the error has a complication...[/quote']

I needed clarity, and I am still not clear on hat happened; and you only told me that you used an IM needle; is it that you used the wrong needle and you gave it the right route, or did you still give it IM???

My question is: did you give the wrong test, and still gave it the right way???

If you have it the right way, fine; it's still a med error; and you still need to contact the patients in order for them to get the right order.

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Waitaminnit-- are you a nurse? An RN, LPN/LVN? Let's get that clear before we go on.

And of course since reporting an error is not about YOU, it's about the patient, you can't decide not to report the incident with the second patient just because it's a lot like the first error.

And your friend who says, "Don't worry about it," is she a real licensed (RN LPN/LVN) nurse? I can''t believe a real nurse would say anything of the kind.

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Specializes in Psychiatry, Mental Health.

I strongly encourage you to report both medication errors. Everyone makes errors; we grow from the experience by 'fessing up and doing appropriate follow-up. It is dishonest not to do so.

If nothing else, these patients are not immunized, and it is important to fix that.

It's GOOD that you feel bad. That means that you are basically responsible. Use that feeling and follow-up. I guarantee you that is not a mistake you will repeat if you follow up appropriately.

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