med errors

  1. I really did it this time!!!!!!!!!! I hung mr X antibiotic on MR. Y. The bad thing is the pt family is the one who pointed it out to me. So I observed the pt for any side effects. The dr. changed him over to amoxicillin that day anyway earlier. So I wrote up an incident report and called DR. and took orders to give bolus of 0.9ns over one hour to flush his kidneys. Did a UA. So I got pulled in to my nurse managers office and got a lecture about the five rights the next day. And add insult to injury got the same pt the next day. Funny thing is the family complained to my nurse manager the doctor. He said he hadn't had any urine out since 7am that next morning til 3pm. I told him that I needed him to try or i was going to have to cath him to observe his kidney function. Well with that initiative he put out 700 clear yellow urine that next 2 hrs. It is true never chart any incident in your nurses notes, I just charted that the pt was stable good output, gave pt 250cc bolus over one hour. I tend to think people think we are incapable of mistakes. My nurse manager was pissed off at first because the family complained but she thought I didn't write up an incident report, which she later found on top of her desk. I know every nurse makes med errors but it quite a pill to take when it is you. thanks for listening Janice
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    About janleb

    Joined: Jun '00; Posts: 261; Likes: 4


  3. by   flashpoint
    As long as the patient suffered no ill effects, I wouldn't worry about it. We're all human, we all make mistakes.

    When assignments were made the next shift, did you ask not to be assigned to that patient? Our charge nurses are really good about adjusting assignments if there is something that makes the nurse uncomfortable.

    Is being nasty a new trend with nurse managers? LOL. Mine will call nurses in and chew them up one side and down the other for anything...whether a valid complaint or a real problem or not, if a family member says something, we're in her office being talked to about it!
  4. by   renerian
    I made a med error once. I felt so crappy. WE are all human....

  5. by   CATHYW
    Yep, me too! I did the very thing that you did-hung the wrong abx-right room, wrong patient! Fortunately, the pt's Dr. found the mixup. He was firm, but very nice. He thought that the pt. was allergic to the abx. I hung-he drove over to his office at 2300 at night and retrieved the office file, just to be sure-thank goodness, he WASN'T allergic! I got the 5 rights reminder too, but I was very thankful that was all! It could've been a LOT worse!
  6. by   canoehead
    If you haven't almost killed someone you haven't been working long enough. Learn and move on- the patient was OK and that's a mistake you won't make again.
  7. by   AndyLyn
    Everyone here's right, mistakes happen, you own up to them and move on. At least nothing bad happened! The 2 med errors I've made made me pay more attention during med pass after that, and even a bit nervous for a while! But, I'm glad that we care if we make mistakes... wouldn't it be sad if it was no big deal?
  8. by   janleb
    I have been on a five day hiatus and just went back to work yesterday. I took my mar with me each time and will continue to do so. Thank you for you support.
  9. by   gwenith
    Learn and move on.

    I wish though we would re-evaluate the efectiveness of lecturing someone over the five "rights" and instead concentrate on WHY the error was made. Did the patients have similar names? What was your caseload? What can you do to stop the error being repeated? Were you stressed by other factors? Were you distracted? I think it is time we, as a profession looked beyond the event and started truly analysing why these things occur and maybe prevent not just one person making the same mistake but everyone making these mistakes.

    One of the stressors that is never considered is the ridiculous labelling on some ampoules i.e. light green or pale yellow on glass. Light brown on brown. Very difficult to see especially in poor light and especially if your eyes are not 100%.
    this is an unconscious stressor that adds to the pressure of med administration. You may not make an error with that drug but because it has put that bit more stress on you you make an error on the next med.

    We talk of holistic view with patient care - let us bring the same skill to medication errors - take a holistic view.
  10. by   Rapheal
    I made a med error last month. Called the doc, the nsg supervisor and wrote and incident report. Got a real cold clammy feeling when I realized my error. I took responsibility for it but in hindsight-I had too many patients and no support. There is a nurse I work with who bragged she never made a med error in 16 years. Last week I overheard her complaining to another nurse about "all these incident reports on me with med errors. I had no idea about them and am not taking the rap months later." Seems that even nurses who think they don't make med errors sometimes do. I have also caught nurses lying about giving meds that they didn't give-yet they say they did. Here is an example from 2 weeks ago. Patient IV antiobotic from 4 p.m. is laying on the med cart at 7:30 pm. It is warm (a refridgerated med). Not marked off on the MAR. I ask the nurse if she gave said med. She replies frostily " I gave it". Hmmmm. Look in the room and there is no IVP of said med. Do I call her a liar? No. As for an incident report----I was too busy trying to figure out what was going on with my patients since the day shift nurse did not chart anything but an assessment on my patients. No safety checks on the flowsheet, no narrative notes, no I&O's. Nothing. I just don't have time to be the nurse police. By the way-I am looking for a better place to work.
  11. by   renerian
    Canoehead that made me laugh.....

  12. by   angelbear
    I made a med error in the LTC facility were I used to work. I worked 3rd and always passed meds just on the one wing. One night my NM asked me to come in just for the 2 hr 2nd shift med pass on the opposite hall that I was used too. Anyway came to this lady I had worked with before looked at the pic in the mar read name on door did the five rights though they did not wear wrist bands but I did call her by name when I gave her the meds. She was totally with it and did not take meds on 2nd at all but she never even batted an eye just took them right down. The minute I walked out the door I realized what I had done. Reported myself did paperwork called MD and family. I cryed I suddenly felt I was not fit to be a nurse. Womens daughter wanted me fired on the spot. Thankfully My NM stood up for me with the DON and nothing happened but boy did I learn my lesson. People do not look the same laying down as they do when they are sitting up.
  13. by   flashpoint
    Today, I had a patient who had vicodin ordered every 6 hours PRN...last one documented was at 0200, I gave one at 1230. Got nailed because the charge nurse gave her one at 1000, but forgot to document it...didn't bother to let me know she gave it either. Got written up, doctor and nurse manager both chewed my butt...sigh.
  14. by   glascow
    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?

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