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 made a medication error, but with the horrendous amount of patients I can see why. In the end it was my mistake, gave wrong medication to 75 y/o patient. No one hurt, but I take extra time to make sure my narcotic count is right and right patient getting medication, even if it takes extra long. I'd rather take a long time then get embarrassed about a medication error. No one called me in to the office, no one wrote me up. One person fed off it, but I expected that and I did defend myself, because I know it wasn't intentional.
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?
My former nursing professor supposedly states that back in the day when nurses made their own IVF, a new grad accidentally administered potassium chloride IV push as opposed to Lasix and killed the patient.
Supposedly the Lasix was ordered SIVP whereas the Potassium was supposed to be injected to the half litre bag of D51/2NS. Well she got them switched up and whoops.
I question the validity of this story, but sounds like a twilight zone episode either way.
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!
These are exactly the policies that encourage nurses to not self report errors. Why on earth would any facility give a nurse that self reports a formal write up? Much better to have a policy in place that allows for investigation on how the mistake happened and ways to prevent it from happening again.
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?
A local nurse was in the news a few years ago after a patient died because she administered the wrong IV med. I believe potassium was the med wrongly administered. Initial reports of course blamed it all the nurse but as the story unfolded it was revealed that she had been on the clock way longer than was considered safe. She did lose her job and was unable to work during the investigation. Her career never did recover. She went into a downward spiral. I can't remember how long after the initial incident it happened but she ended up dying in a single car accident. Alcohol was involved in the crash.
These are exactly the policies that encourage nurses to not self report errors. Why on earth would any facility give a nurse that self reports a formal write up? Much better to have a policy in place that allows for investigation on how the mistake happened and ways to prevent it from happening again.
I was under the impression that our self reporting worked that way. I can see how this would discourage self reporting, which can be disastrous if the error is potentially serious.
Truly unfortunate, but lesson learned. Never give someone else's med, unless you have had a look at the Medes and verified that it is the correct med for the correct pt; and yes, I have made this error also, wanting to help a swamped friend. Fortunately, there were no adverse outcomes. I found it better to offer to do something else she needed done, so that she could do her own meds. You will have plenty of opportunities in your own practice to make this type of error, let each make their own! How about a double room with 2 old ladies, virtually the same meds, same last name! It has happened to me. Always use extreme caution when giving meds; we are the final safeguard, after all is said and done. Relax and move on, but always be alert!
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?
So happy that you learned this lesson without serious complications. These kinds of hard lessons and graces help remind us to never do it again. Always take the MAR with you, especially when it is not your patient. Many patients trust us and will take anything we give them, thinking the doctor just ordered something new.
We have antibiotics that are not pre-mixed, the diluent comes with a vial of antibiotic powder that is then reconstituted with the diluent right before hanging. When you set the powder on the diluent port, you squeeze in diluent, mix the vial, then squeeze it back into the bag. One time I was rushing and forgot to squeeze my mixed antibiotic into the bag, so my patient just got the plaim saline diluent. I realized it when my pump beeped complete and I saw the vial still full of liquid medication. I was upset, naturally, because it made me realize that I was being sloppy in my med pass by trying to go to fast. It was an easy fix, no harm no foul, but i felt like an idiot. Thankfully this patient was not on strict I/O and when I saw the doc later that day he thought it was comical. He wrote a funny order for 100ml NS flush to check IV patency before giving antibiotic to cover the extra saline, haha. This pt did not have a continuous running line , so it kind of worked. I learned a valuable lesson and moved on.
Side note, I also want to caution you to quickly check your infusing IVs when you receive report from the nurse leaving. If they have the wrong thing hanging up, it's also your med error if you dont catch and correct it, even if you didn't hang it. I had a friend learn that the hard way.
A local nurse was in the news a few years ago after a patient died because she administered the wrong IV med. I believe potassium was the med wrongly administered. Initial reports of course blamed it all the nurse but as the story unfolded it was revealed that she had been on the clock way longer than was considered safe. She did lose her job and was unable to work during the investigation. Her career never did recover. She went into a downward spiral. I can't remember how long after the initial incident it happened but she ended up dying in a single car accident. Alcohol was involved in the crash.
Specializes in Medsurg/ICU, Mental Health, Home Health.
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.
How on Earth was this allowed to happen? I can't believe that they were even on the same floor, unless it was a really small hospital or a very specialized department.
We once had three Wilsons on the same floor - each had to be in a different district.
Specializes in Acute Care - Adult, Med Surg, Neuro.
I have made med errors before that have no affected the patient in any way, thankfully. I have had 1 patient who transferred from a different area where there was a major med error that happened with them, but I can't go into details. It was due to the previous RN not using the bedside barcode scanner and involved a high risk IV medication. The patient survived but it could have been extremely bad. Sometimes I think that with the stress and workload we have these errors could happen to anyone, and it terrifies me. The thought of harming or killing one of my patients is a subject of many nightmares. There by the grace of god that I slow down, triple check, and keep my patients safe.
neuron
554 Posts
I made a medication error, but with the horrendous amount of patients I can see why. In the end it was my mistake, gave wrong medication to 75 y/o patient. No one hurt, but I take extra time to make sure my narcotic count is right and right patient getting medication, even if it takes extra long. I'd rather take a long time then get embarrassed about a medication error. No one called me in to the office, no one wrote me up. One person fed off it, but I expected that and I did defend myself, because I know it wasn't intentional.