Medication ERROR

flashpoint · Feb 23, 2005

I'm not quite sure what exactly you are asking, but I will try to answer. Our nurse manager believes that nurses are humans, and thus will make errors. We do our best to avoid errors, but sometimes they happen. We do three checks (check the medication label, compare it to the order, compare it to the order again before giving it to the patient). Anything for a pediatric patient, we have two nurses check before it is given. Anything that we don't give a full tablet, unit dose, syringe, or whatever...two nurses check. If we make an error, we are expected to admit that we did and do whatever is needed to "undo" any harm to the patient. Rarely, is there any disciplinary action, unless we try to cover up the error or something like that. Sometimes, depending on the error, we have to read some literature or something about the drug or regarding the error, but we are rarely "punished." In the seven years I have been at this hospital, I've seen only one nurse that made an error that was serious enough to require discipline...he is working with a mentor for the next six months and is not allowed to give any medication until he takes a phamacology / medication administration review course. He's also not allowed to function as a charge nurse and cannot be the "second nurse" to check calculations, dosages, double check insulin, etc. He made a major error that he might lose his license for...he might also have some criminal charges filed against him and will very likely be sued.

stidget99 · Feb 23, 2005

If someone in ER made medication ERROR???? hows the process being done? Are the managers cover the staff? Is this staff be councelled? suspended? answerable? How you all nursing managers here go about it?
I would like to know your ideas of how things to be done.......as far as medication error is concern in my nursing life......is not a joke..... we cant afford to do that......as far as patients safety is concern.....we have to avoid that thats the reason we have license in the first place?
I need to know your ideas about this .....hope you can share something for me. My fellow nurses here are trying so hard to understand the system of where we are working......
Asereht

Nurses WILL make mistakes. Any nurse who tells you that they have NEVER made a medication error are lying. We all do it. However, owning your mistake to minimize harm to the pt is what counts.

At the hosp where I work, reporting of incidents (med errors or some other event) is strongly encouraged. It is not a matter of hours and hours of paperwork to report the incident...it's a matter of making a phone call. The end result to the person who made/reported the error is non-punitive. The hosp believes that if we are not afraid to report errors, then we might be able to better identify WHY or HOW errors happen and possibly make changes at a higher level to prevent future errors. Now if one person is continually being reported for med errors, then they are counselled accordingly.

aserehtbread · Feb 23, 2005

I'm not quite sure what exactly you are asking, but I will try to answer. Our nurse manager believes that nurses are humans, and thus will make errors. We do our best to avoid errors, but sometimes they happen. We do three checks (check the medication label, compare it to the order, compare it to the order again before giving it to the patient). Anything for a pediatric patient, we have two nurses check before it is given. Anything that we don't give a full tablet, unit dose, syringe, or whatever...two nurses check. If we make an error, we are expected to admit that we did and do whatever is needed to "undo" any harm to the patient. Rarely, is there any disciplinary action, unless we try to cover up the error or something like that. Sometimes, depending on the error, we have to read some literature or something about the drug or regarding the error, but we are rarely "punished." In the seven years I have been at this hospital, I've seen only one nurse that made an error that was serious enough to require discipline...he is working with a mentor for the next six months and is not allowed to give any medication until he takes a phamacology / medication administration review course. He's also not allowed to function as a charge nurse and cannot be the "second nurse" to check calculations, dosages, double check insulin, etc. He made a major error that he might lose his license for...he might also have some criminal charges filed against him and will very likely be sued.

As far as nursing responsibility and adminsitration of medications is concern we are also doing the same ways and exercising the rights of the patients accordingly, but what is the problem now is how these head nurse and managers able to handle such, as far as you mention we are doing the same actions, in the Philippines where I am registered as BSN RN. If there will be a staff who made a mistake and acceptance of what you've done will resolve and can be taken actions accordingly too........BUT these nurse managers are not doing anything for this matters to the staff who made the error, instead they screwed up the system.......as assistant nurse they restrained us of giving medications......and I was able to brought up with them that how can this nurse managers able to know the flow of work in ER, ..........this is the situation now, I waited for my SSN( SENIOR STAFF NURSE) to give VENTOLIN NEB. and I need to shout for my SSN in RESUSCITATION ROOM TO GIVE S/L GTN, ASPIRIN 300 MG for patients having chest pain when doctor ordes or even to give a simple paracetamol to patients having fever we can't give because they restrained us not to give. I told them because of the mistake of one person that they presumed to be qualifed and they do nothing about it. DO YOU THINK THERE IS SOMETHING WRONG HERE? Some of my colleuges were telling me...well no point of talking to much Asereht...because this woman has the big head in the hospital...... I FEEL REALY VERY BAD!!!!!!! and until now they haven't done anything to the staff at all. POLITICS ARE REALLY VERY BAD HERE!!!

My dear Nurses yes we are just HUMAN and we are prone to commit mistake but...for me.....Im not trying to be perfect, I can't afford to do that when it's my patient's life is at stake. ERRORS CAN BE PREVENTIVE...... and ERRORS CAN BE AVOIDED..... and thats why we were trained to be one of the medical staff. Whats the use of our license in the first place....but my point of view here ........obviously they know and indeed it was accepted it was medication error but they didn't do anything at all!!!!! But just to make us useless in front of asthma patient and we cant even give a ventolin ned right away!!!! DO you think it is reasonable.

I feel sorry for the patient, and for the management that we have here...... they became NURSE MANAGER'S but they dont know much in nursing legalities. I can only air out this to all of you that Im sure knows a lot of things in a way that we are nurses, with knowledge and skills......and expertise. Thank you for all your ideas I appreciate it very much.

aserehtbread · Feb 23, 2005

Nurses WILL make mistakes. Any nurse who tells you that they have NEVER made a medication error are lying. We all do it. However, owning your mistake to minimize harm to the pt is what counts.
At the hosp where I work, reporting of incidents (med errors or some other event) is strongly encouraged. It is not a matter of hours and hours of paperwork to report the incident...it's a matter of making a phone call. The end result to the person who made/reported the error is non-punitive. The hosp believes that if we are not afraid to report errors, then we might be able to better identify WHY or HOW errors happen and possibly make changes at a higher level to prevent future errors. Now if one person is continually being reported for med errors, then they are counselled accordingly.

Thanks for your idea. Yes, we are not perfect and we can make mistakes but how this mistakes be brought up to the staff concern and how this error can be avoided. If this incident will happen again, meaning you want this nuses managers to do the same of what they are doing now to restrained junior nurses to give medication. Its only a mistake of one person not all of us... How can this we able to identify the risk of making an error if we dont have nothing to worry........there should supposedly an investigation to make and suspension of the staff to give medication for the meantime until she will be able to know her mistake.....nothing was done to her, she can still go to work and feel very happy that it seem nothing happen at all.......

I really dont like it because I was the one who caught her and she never ask anybody to counter check with her, and was confirmed when I was able to ask the pateint but I never reveal anything I just normally ask the patient what he recieved for his medication.......the patient shouldn't be given any injection but only Oral MMT 15 mls but she gave ATT 0.5 mls injection, and to prove to that she wrote that explanation was given to pt. the importance of injectionin the nursing notes, but patient dont have any broken skin or wounds at all but complain of abdominal pain. Poor assessment. An the in charged cover her up she amended the notes.....See how this people try to cover up.....but they can not escape from me...... I brought it up to the matron concern. A mistake should be corrected not to be covered up.

Thanks for your idea..... Im glad to hear from you.

I feel bad...about the incident and nothing has done to the staff concern.