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?
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.
I am curious now. When I was in the hospital, self reporting meant NO punitive action.
How do you suppose, your facility differs?
I was told there is no disciplinary action in regards to the write up. My guess is that it stays in your file in case you make similar mistakes, (maybe 3 strikes you're out?) or to be used in the yearly evaluation. It's a bummer, I'm not sure if it will block me if I decide to transfer units one day. Hopefully not
Our reporting process is also deemed "non-punitive" but I read the fine print during orientation and found out that it's non-punitive IF it's deemed a systems error. I can't tell from your account if it was, but I wonder if that's the case for your facility, too. It seems so disingenuous to tout it as "non-punitive" when there's such a huge asterisk [emoji19].
Was this hospital/rehab/LTC? Because in hospital or rehab I would expect patients with same last names to be assigned to different nurses. That wasn't very safe to start. It's more difficult to avoid that in LTC though, which is why I asked.
My hospital is supposedly non punitive also... But that's not the actual way it works. After completing an incident report you can still be written up.
I'm glad you did what you were supposed to after the error. Could have been big (if that patient had an allergy, especially) but no harm came to either patient and now your employer knows you are honest.
I made my first med error this week as well. Went in to give my patient medications. Did my 5 rights. Opened all pills. Set his Lovenox down on the counter. Gave him the pills. Forgot about the Lovenox. Saw it later that day. I feel so bad. Anyone could have gotten that syringe, it was just sitting there. I self reported but still feel terrible. What a dumb mistake!
Was this hospital/rehab/LTC? Because in hospital or rehab I would expect patients with same last names to be assigned to different nurses. That wasn't very safe to start. It's more difficult to avoid that in LTC though, which is why I asked.
My hospital is supposedly non punitive also... But that's not the actual way it works. After completing an incident report you can still be written up.
It is a hospital, but a very small one. We ship out almost anything critical, we almost serve as an urgent care that will house patients for a few days for uncomplicated things such as IV antibiotics for an uncomplicated infection. I haven't had two patients with the same name yet, hope that doesn't happen but if it does I know now I will be extra careful!
I thought that our policy for reporting was non-punitive also, I thought it was used more for figuring out what went wrong. It might actually be for some cases, mine happened to be non-system related and just plain ol bad judgment on my part.
Once the "what" is figured out and patient harm (or lack thereof) assessed the most important aspect to me is "how" What did I do or not do? What were the other factors involved doc, pharmacy, fellow nurse, system error? I want to know how to change my practice to prevent this from happening again. The write-up is meaningless. It won't scare me into being a better nurse. I'm way ahead of that.
If it's a system error I'll work with the system involved to make it better. I'll e-mail my unit if I think it will help. For example Pharmacy accidently put Demerol 50mg/ml injection doses into the 25mg/ml Demerol drawer in the Pyxis. No one was harmed, I caught it before I gave the dose but I sent it back and wrote an e-mail to everyone to remind them be sure what you're pulling out of the drawer before you give it. We are the last line of defense for our patients.
I agree, you learned a valuable lesson for dirt cheap.
Just wondering, does anyone have stories of a medication error where the patient ended up dying because of it? Or know of anyone who has gone through it?
I was once given two patients with the same exact name. First, middle, and last. Lets say it was Mary Sue Jones. Both were little old ladies. I complained as soon as I was given the load but nothing was done. Thank goodness no errors were made.
A med error I did make: My pt was on magnesium protocol. I replaced her magnesium-2 runs- then later dug deeper to find that night shift had replaced her right before shift change. Night shift never replaces because usually labs aren't back in time, but this day they were and night shift thought they would help out. I wasn't told in report about the replacement but I should've looked prior to giving it.
I made a med error a couple of years ago, resident was supposed to get hydrocodone/APAP 5/325 and I gave 7.5/325. I was SO upset! Notified MD, he laughed and said if that's the worst med error I ever commit, all was good. He said, over the phone, "hold out your left hand, palm down. Now take your right hand and slap the left. Now forget it. You're a great nurse!"
When I told the resident what I had done, she said "so I got MORE of the "good" stuff?". I said yes, a little. She laughed and said she liked that kind of error!
The way we stored narcs was not the best and tweaks were made to hopefully eliminate the type of error that I had made. We discovered the problem during the shift exchange narc count. Don't EVER skip a narc count or "trust" the nurse ahead of you!!
Shortly after I switched from days to nights I made a big, shameful med error. I was having a great night until my final med pass of the morning. One of my patients had two (different) drawn up medications in 3 mL syringes. One was to be given IV push and the other IM. I thought I was doing good and even labeled each syringe with a colored sticker that had the name of the medications. At the last moment, I decided to change up what color I wanted to use for each med. When I went into the room, I think I was hurrying and recalling my original sticker choices and gave the IM medication through the IV route ! I know some drugs can be given either route but this was a drug that definitely could not.
I told my charge nurse and followed protocol. But I felt so sick and worried. I even called during day shift to make sure he was okay. WE called a pharmacy and found out that this mistake has happened before. Thankfully it doesn't cause any bad effects but given IV instead of IM does not make the medication effective. I am super careful when having to give multiple syringe medications to patients and double check the labeled stickers before giving them. I hated that this happened but it is so true when people say "It only takes one medication error" to learn to take your time and practice medication rights.
It sucks- but you have learned your lesson. It will happen to most of us at least once.
! I know some drugs can be given either route but this was a drug that definitely could not.
ScrappytheCoco
288 Posts
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.