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Discussion

Medication error

I made my first medication error and it was a big one. I was done with my med passes for the day, and a coworker of mine was swamped and asked me to give her 1200 antibiotic to one of her patients. It was a PO Keflex. She already had the medication pulled, so I went in and gave it. I will just call the patient Mr Smith. She said it was for Mr Smith in room 105. I went in, introduced myself, then said "Mr Smith, I am going to give you your antibiotic". I checked his armband and then gave the medication. He took it and then said "so what infection do I have?"

I quickly went to my coworker and asked if he had been getting this medication for a while. I just had a bad feeling. She said "Oh no! I meant that the patient was in room 107! I'm so sorry!"

It turns out this patient has the same last name as the patient in 107. At this point I feel like I'm going to vomit. I just gave the meds to the wrong patient. I should never have agreed to give a medication I had not pulled myself (I do know it was a Keflex though bc I give it frequently)

I quickly made sure this other patient had no allergies and notified the MD. I am not expecting to get fired or anything like that. I followed all the steps needed for med errors. I still feel really terrible about it though. This is an awful feeling.

Anyone willing to share a med error story to make me feel less, I don't know, alone?

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    O please no big deal. Partly a Systems error, they had no business having two Smiths next to each other. Next time check the MAR and the full name on the ID band. 5 rights and all.

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    I would have been happy to administer the med, with the MAR in front of me. Any time you are handed a med, you are still responsible for the 5 rights.

    Obviously, you did not check the MAR. Hugh lesson, learned dirt cheap.

    I made a big med error as a newbie. Agency nurse in a nursing home. Handed Patient A .. Patients B's cup of meds and vice versa.. nobody died.

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    • Author
    I would have been happy to administer the med, with the MAR in front of me. Any time you are handed a med, you are still responsible for the 5 rights.

    Obviously, you did not check the MAR. Hugh lesson, learned dirt cheap.

    I made a big med error as a newbie. Agency nurse in a nursing home. Handed Patient A .. Patients B's cup of meds and vice versa.. nobody died.

    Definitely a huge lesson learned. Never want to feel this feeling again! The careless nature of my mistake is what makes me feel so lousy.

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    Yes, I gave the meds to the wrong man once. It was dilantin and serax. Nobody died. It's a humbling experience for sure.

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    Any nurse that says they have never had a med error is either lying or don't realize they have made one. It just may also mean that it still has yet to happen. We all make them, We all feel lousy. Recognizing what went wrong and to be watchful that it never happens again is very important. You now know that you won't make the same type of med error again.

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    This really isn't a huge medication error. He was not allergic and no one died. This is like stealing a cookie from the cookie jar before supper. It'll be okay. Learn and move on.

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    • Experts

    As a newbie I gave double the dose of an antiarrhythmic bolus IVP- I was being rushed by the charge nurse/monitor RN and the bag it came in was not marked as a partial dose ... Def a systems error but I was the last line of defense before it got to the patient...I blame only myself. The patient became slightly hypotensive and bradycardic for a brief while, I paged the surgical chief resident on call practically in hysterics...the patient quickly returned to baseline and even returned to rapid afib...have never made a dose mistake since then and I thought I was gonna die. Everything was ok and it was actually pharmacy that got written up for not putting a "partial dose" sticker on the bag.

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    I gave a client a monthly Haldol injection approximately an hour after someone else had given it to him. (She signed off on our IM log, not his MAR). He was still within the acceptable guidelines but did receive double his normal amount of Haldol. It all turned out OK.

    Med errors happen. Learn from it and move on. :)

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    • Author

    Thank you for your stories! I didn't mean to sensationalize the error I made, I know that its a minor one in the grand scheme of things. It felt monumental in the moment. I think being able to talk about it makes it sting less.

    Unfortunately, even though I did exactly what I was supposed to do incident report wise, calling the MD and the follow up, my boss notified me that I will be getting a formal write up. I thought it was more of a non-punitive process, but I guess you live and learn!

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    Unfortunately, even though I did exactly what I was supposed to do incident report wise, calling the MD and the follow up, my boss notified me that I will be getting a formal write up. I thought it was more of a non-punitive process, but I guess you live and learn!

    Key here? You did what you were supposed to. You can move forward with a clear conscious. (Totally sucks that you're getting a formal write up. Our facility has med error forms that document the error and the steps to prevent it from happening again, but it's but a formal write up).

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    I am curious now. When I was in the hospital, self reporting meant NO punitive action.

    How do you suppose, your facility differs?

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    I gave a trauma pt an im injection of solu-medrol instead of a tdap because I had both syringes in my pocket and didn't label. He died but not because of my error.

    5 rights

    5 rights

    5 RIGHTS. :saint:

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