Medication Error how to pick up the pieces.

[itsmethestina]

I have been a new nurse for approximately 4 months. I have started my RN career in a Pediatric hematology/rheum/immunolgy setting. I made my first med error after only being off orientation for 2 weeks. I accidently gave solumedrol 15 mg/1.5ml subcutaneously instead of lovenox. I did my five med rights, checked the patient, mom was at bed side. I went in a systematic way, did my oral medications first, then went to do my subcutaneous, then my IV. Thant is when I realized that I had grabbed the wrong medication. I noticed that when I went to put my IV soluemedrol on the pump that it was the lovenox. I had attached the needle to the solumedrol and administered it subcutaneously. The child mentioned that it had burned but I didnt think anything of it since lovenox does burn. I immediately gathered my supplies, medications and went to my charge nurse. I was so horrified and upset. I am a mother and I know how upset I would be if the roles would have been reversed. I am now questioning my self and whether this is the profession that I should be in. I always wanted to be a peds nurse, and now fail, I unintentionally made a medication error on child and created more doubt in a family that is already scared about what they are facing with their childs health. I later had to change out tubing on another child who had, TPN, lipids, PCA morphine, fluids and chemotherapy to be started that same evening. The lines were a mess when I went into the room, I applied a systematic approach and started with one line at a time. The lines were such a mess that it took forever. Soon, after I have the fluids hung, i move to the TPN and lipids, lines are primed, I go to open the PCA pump and attach, prime that line, I hook up to the child and everything is going then dad and I realize that their is air in the line and so I unattach the tubing, prime again to get out the air. But dad notices a bubble in the CVL line. My charge nurse then comes in and says that is okay, so I hook back up. However, I was going to take out the bubble and get the air out of the line. Then I started questioning myself on why it took me so long to do all of these new tubing lines and what is appropriate amount of air in the line to not freak out about. In school I was taught no air period!!! Now I feel like I am a hotmess, all of my co-workers im sure will be aware of my mistakes which will lead to me being the talk of the nest few weeks. In the meantime, I am doubting myself, my confidence is shot, and I am now questionging if this is where I am suppose to be. Im truly broken hearted right now

[BluegrassRN]

So, what did you learn from this error?

Unfortunately, you have a job in which, if you make an error, it affects another person directly. That's the way it is. Every time you mess up, you could harm someone. We all have to make this realization at some point, and yes, it's a scary thought.

You can either fall to pieces, learn nothing from this, and be a bad, unhappy nurse, or you can look at this as an opportunity to learn and grow. Critically examine your error. What did you do right? Where did you make the error? What events led up to this error? What will you do differently next time to insure this won't happen again? For example, did you draw up the syringe with the solumedrol before entering the room? Does your lovenox come in prepackaged syringes that can remain unopened until the time of administration? Were you chatting and distracted?

All of us have made errors. My own worst was when I mis-programed a PCA pump and ended up giving someone 10X the appropriate dose for 2 hours. The nurse who double checked my programing missed it as well. Several factors contributed to my error, including my own inattention. I am now the go to nurse for double checking PCAs, because I check them so thoroughly. When I recognized the error, after I got over the completely horrible feeling of "Oh my god, I could have killed this person", I critically and honestly examined why the error happened and what I could do the prevent such an error from ever happening again. Environment, distraction, rush, inattention, and faulty equipment all were factors, most of which I could address (and this was THE error which made my hospital decide to order new PCA pumps to go with our new IV pumps, by the way, so the systemic/equipment error was addressed hospital-wide).

Good luck!

[rnsrgr8t]

Everyone makes medication errors. I remember having to give to different IV medications. They were in the same size syringe and same volume and both were clear (it was a long time ago and I cannot remember what meds they were). I looked in my patients med bin , saw the med I wanted but grabbed the other one and gave it in error because I did not recheck the label when I hung it on the IV pump. The lesson I learned from that is just before I give the med at the bedside, I look at the label, one more time, to make sure I am giving the right thing, the right way. This is in addition to the normal 5 rights that we are taught. I think doing that would have helped you in this situation. It is easy, when you have a lot of meds to give and are frazzled to mix up and put the needle on the wrong syringe. Checking the label as you are preparing to give it at the bedside can save you on that. When I did that last check, I would say in my head what I was doing (Lovenox such and such a dose, SQ and solumedrol such and such mg IV over 20 minutes (as you hang it on the pump) If you can learn from it, that is all you can do. After you get over the initial horrible feeling, take a deep breath and move on and learn.

[Been there,done that, ASN, RN]

Just curious, did the lovenox vial and the solumedrol vial look anything alike?

Four months and 2 weeks off orientation is very little experience. Will you be counseling regarding this issue?

In the meantime, after you have prepared your meds,and applied the 5 rights, ( I always say 6 rights, as I add... for the right reason)... check 2 more time before any injection or IV push to make sure you have the correct drug.

The amount of air in a line should have been taught during orientation.Approach you nursing educator and find out the answer for your facility.

It is impossible to get out every air bubble.I have been taught that tubing, completely full of air, will not cause an air embolism.

(No, I don't bolus anybody with 20 cc's of air).

Good luck peds right out of school is a challenge, don't give up on yourself.

[iluvivt, BSN, RN]

No you do not need to throw in the towel..you do however, as stated need to really examine how the error occured and what you need to to do to prevent another one. It sounds like you brought all the medication in at once and then did your 5 rights and starting administering. If that is the case I can see how easy it would be to mix things up. You need to be very very careful with IV medication b/c it is a very direct route into the body with immediate effect and in many case it is difficult to counteract. If I had several medications to be given that had different routes or even different rates of administration..I would do something to alert me..for example...I may have labeled the IV medication with a bright sticker...I might have seperated the medication by route...so for example give all po things first...then..SQ..last IV push.. or even check IV med twice as stated above.I may have even brought my IV medication in all by itself..or left everything else in the med server. It is better to take a few extra minutes than to deal with the agony of medication errors. To this day...I still walk all of my sharps to sharps container all by themselves...no other trash will be in my hands....(safety sharps help) b/c I saw so many nurses get needlesticks cleaning up after IV starts and medication administation. When I am administering medication I really try to keep the distractions to an absolute minimum. There are many hospital systems,recognizing this as a huge problem DO NOT allow nurses to be distracted during medication administration.

[itsmethestina]

The lovenox shot was not pre packaged, it was in a tube with a green label and yellow top just as the solumedrol was. I had only given pre packaged lovenox shots in the past. However, you are correct about examining this mistake to find what I did do wrong. I made the mistake of laying out all the syringes on the counter to check them. I now will do one thing at a time, I will leave medications in their packaging, checking one at a time. I will triple, quadriuple check the medication before it is given to the patient making sure of the right route. This was definately an eye opener and a lesson learned for me. A very tearful and hard one.

[londyrn]

I love all of your positive comments. I have a question. A dialysis nurse made a mistake. She dialysed a dialysis patient on the worng day. she took a verbal order and never varified the orders. She realised her mistake in the middle of the treatment. She got verbal orders, she reportedher mistake to her supervisor, patients doc, patients nurse. She was sent home on suspension with pay. No harm to the patieint,and she self reported her error. What will happen to this nurse? Or what do you think should happen to this nurse? Has any one ever had this experieince if so what happened.

[jadelpn, LPN, EMT-B]

To the above poster, a lot of places now don't allow verbal orders to be taken just for reasons such as this. I am not sure how someone takes a verbal and doesn't verify, repeating back the order, but none the less, it is not great practice to take verbal orders unless it is an emergency. If the patient showed on the wrong day, she started treatment, THEN realized it was the wrong day and got an order to cover it, that is also poor practice, and I am not sure waht can happen in that instance--but the MD did cover it, so she is lucky in that instance. But if in fact she had an order prior to treatment, that is the doctor's decision and she was carrying out the order and not that I am any expert on dialyisis, however, can't a patient be dialized for say a medication clearance, or some such thing, so that it would not be unheard of? I am not sure however why one would self report if they had an order to begin with.....

TO THE OP:

I am a HUGE fan of neon labels and fine point sharpies. Label ALL of your tubing, label all of your meds. It is really, really easy to mix up a bunch of tubes wires whistles and meds. It is a good idea to leave everything in the packaging. It is also a good idea to draw up at bedside one med at a time. It is also a good idea on your initial assessment of the patient to straighten out and label all of the tubing. Neon different color labels, with block lettering. I do think as a brand new nurse in such a complicated patient population that a few months is a little time to learn all you need to. With that being said, you can organize yourself as to not mix up what you need to do, and personally I can't imagine all that going on at once. If your patient poplulation gets "nervous" with you drawing up at bedside, then just turn your back a little. Good luck, you will get organized, and use your charge nurse as a resource to double check your meds--that is what she is there for, and you are a new nurse, and what you do is complicated so to be sure for awhile, ask her to verify with you.

[Liddle Noodnik]

I hate to tell you how many errors I have made SO frustrating given how careful we are - but yet, we are rushed, or maybe, confident we are careful ENOUGH. It makes me so ashamed. All you can do is learn from it, know you are human, and know that as a nurse you almost have to be LESS human ... we know what awful damage the wrong drug/dose/etc. can cause.

PLEASE do not beat yourself up. You aren't alone. and yes, make sure you identify what it was that messed you up. xoxo