Medication Error

[BSNRNINRI]

Hello. I am a new nurse and recently graduated 7 mos ago. I am employed in a LTC facility.

I just started working there 5 weeks ago and was trained on one floor. Last week they decided to put me on another unit-a dementia unit and none of these patients have ID bracelets. The only identifiers are pictures in the MAR and on the doorways of the patient rooms. I went to a room to give meds and both patients in this room were to receive meds at this time. I went to the room and looked at the wall before entering and read the patient name and observed the picture below it. I gave the medication to the patient whom by the way.....was aphasic and very confused. I went back to the med station and proceeded to get the medication for the other patient and this is when I realized I had confused the patients. The name I had read was above the other patients picture! This patient refused to have his picture on the wall so this is where the error occurred on my part. I immediately reviewed the records and checked for any adverse outcome but thank goodness the patients were on similar meds so there was a small chance for a reaction. I immediately told my supervisor hat had occured so the patient could be monitored. I had to write an incident report on myself an I feel totally discouraged now regarding my patient safety skills. I was on my first day on this unit and I was by myself. I cannot stop beating myself up over this incident and I was suspended until the DON could review the problem. I am really distraught ove:(r this and I am unsure what is going to be done as far as disciplnary actions. Any advise?

[CrunchRN, ADN, RN]

Geez. What a system? I think it is a set up for failure. How hard can they have it be too identify the patients?

[HouTx, BSN, MSN, EdD]

I can understand your concerns. However, the lack of wristbands is not unusual in LTC or other residential facilities. I suggest that you review your facility's policy & procedure to be sure you understand it and make sure you are following it to the letter. When you talk to your DON, tell her what you have learned from this incident and how it has affected your practice. It seems as though your error had to do with lack of understanding of the placement of the names vis-a-vis the pictures. I am sure that this won't happen again now that you understand it better.

If you feel that it can be improved for patient safety (perhaps by putting the picture & name in the med book or attached to the MAR?) you should suggest this to your supervisor. Be sure to voice it as a suggestion to improve patient safety rather than as a criticism so that no one can come back at you as an uppity new grad.

[dudette10, MSN, RN]

I have yet to understand why residential facilities don't use wrist bands. LTC residents come into my hospital all the time with plastic bands on their arms from their facilities. Why do other facilities insist upon NOT using them? It's for safety!!!

[MomRN0913]

This is not your fault. This is a horrible identification system. It's one thing if they are alert and oriented patients who could speak. If this patient did not want his face on the wall, he should be wearing a wrist and.This is a very dangerous system. Please don't berate yourself.

[canned_bread]

I have been in a very similar situation (with the same picture/name system!) whilst working at a nursing home, and I did the patient's that looked unique and knew their name, and then asked for assistance from an AIN who had worked there a long time and knew the patients thoroughly. The system is NOT safe, but I think you should have had help from someone who knew the patients. Although you would still be culpable, being the RN administering the medication, if something went wrong, you have placed another safe guard in place.

The mistake you made was very easy to make, there were a lot of barriers in your way. I do not think this is your fault.

[Anne36, LPN]

Ive been in similar situations and almost did the same thing. I hate that there is not a fail proof way of identifying the residents. (no id bands here either). Imagine being on a hall with over 30 residents you dont know who are in their wheelchairs all over the building and have to do med pass. Thats where I was last week and I had to rely on my CNA to identify the residents. They were great CNA's but I do not feel comfortable relying on them for this critical information. Why do these LTC facilities think they can float Nurses all over the place like this? I worked another floor 2 days ago this way and Ive had it.