Medication Error

Sour Lemon · Mar 26, 2019

3 minutes ago, jeane1090 said:
Over the weekend I made a really silly mistake and I have been so anxious and upset ever since. Due to my anxiety and wanting to be a thorough nurse I always review my MAR at least once every hour, sometimes even more if I have time to kill. Somehow, even through my consistent checks, I missed a 0600 dose. I had this patient for night shift on Thursday and Friday night. On Saturday morning I was reviewing my MAR and went to administer the patients medication of lasix 80mg PO BID. I then realized that I had completely overlooked this medication somehow the previous morning so it was not administered. I filled out an occurrence report and called the doctor on call. The patient was fine but I am so upset at myself for this mistake. At this point I feel numb because it is all I have been thinking about for the last 3 days. I am terrified to go back to work even though I want to so badly.

That's one of the best types of errors to make ..."small potatoes" in the grand scheme of things. You have my permission to move on and be happy.

Iheartwoundcare, MSN, APRN, NP · Mar 26, 2019

Breathe. Tell me... are you a robot, or are you human? You made a mistake- and it probably won’t be your last. You sound worried about the patient and that makes a good nurse.

You did the right things- you called the doctor and wrote an incident report. What else would make you feel better?

Move on and keep being a good nurse.

**CalicoKitty, BSN, MSN, RN** · Mar 27, 2019

Honestly. Nursing is also a 24 hour job. The oncoming nurse should have also noticed it. Those "shift-change" meds (6/7/8) are easy to miss. During shift change, it is a good idea to review the MARs of the patients (and also look for missed labs, etc). In the beginning of my shift, I try to take a few minutes to "prepare" by checking all my med times. Sometimes I write the numbers and cross them off as given. Other times I use a grid. It helps.

Jory, MSN, APRN, CNM · Mar 27, 2019

On 3/26/2019 at 12:28 AM, jeane1090 said:
Over the weekend I made a really silly mistake and I have been so anxious and upset ever since. Due to my anxiety and wanting to be a thorough nurse I always review my MAR at least once every hour, sometimes even more if I have time to kill. Somehow, even through my consistent checks, I missed a 0600 dose. I had this patient for night shift on Thursday and Friday night. On Saturday morning I was reviewing my MAR and went to administer the patients medication of lasix 80mg PO BID. I then realized that I had completely overlooked this medication somehow the previous morning so it was not administered. I filled out an occurrence report and called the doctor on call. The patient was fine but I am so upset at myself for this mistake. At this point I feel numb because it is all I have been thinking about for the last 3 days. I am terrified to go back to work even though I want to so badly.

Sometimes being overly anxious can cause you to make a medical error. What area of nursing are you in? While it is important to check your MAR, checking it more than once an hour is completely unnecessary. There is more to patient care than just medications.

A bigger question is why didn't the next nurse notice that the medication had been missed and told you this in report. If it was early morning she should have noticed the dose had been missed and called the pharmacy to administer the dose and ask the frequency be reset. That way the patient didn't go a whole day without it.

Medications administered around shift change are frequently given on off times because there is a lot going on. So don't beat yourself up too badly.

Irish_Mist, BSN, RN · Mar 29, 2019

It sounds like your anxiety about making a med error is what might have led you to missing this lasix dose. Take a deep breath and relax. Going over the MAR multiple times every hour is not necessary. All this will do is make you anxious. This is a very minor event, the patient is fine, you are fine, and all is well. Move on and forgive yourself. You are just as much of a human as any other nurse and you will make mistakes but the important thing is to learn from them.

My suggestion to you is to find some sort of way to get past the anxiety you have. I have dealt with depression and anxiety all of my life. I take medicine for it and I see a counselor. Both of the aforementioned have made my personal and professional life SO much easier. Maybe you could do one or both of those if you can't find a way to establish your own healthy coping mechanisms. No nurse wants to make a mistake but if you are constantly living in fear of making a mistake, it will probably make you more likely to actually make a mistake.

Forest2 · Mar 29, 2019

We all make mistakes, and what is your percentage considering the vast number of medications you give? I know you care or else you wouldn't feel so bad. Don't be so hard on yourself. You and I are not infallible.

Meriwhen, ASN, BSN, MSN, RN · Mar 29, 2019

On 3/26/2019 at 9:12 PM, CalicoKitty said:
Those "shift-change" meds (6/7/8) are easy to miss.

Plus, if it falls right at shift change, each shift may think that it's the other shift's responsibility to give it.

Back to the OP: While I'm not downplaying the seriousness of medications errors...as far as med errors go, this one wasn't all that bad. I presume the patient came through unharmed. Learn from it, forgive yourself, and move on.

TriciaJ, RN · Mar 29, 2019

The patient missed a morning dose of Lasix. Then got his evening dose and the next morning's dose. And lived. You discovered it (no one else did previously, so it became a systems error), slapped yourself on the forehead (I'm sure you did), called the doctor and completed an incident report. That's it. Now you move on.

When you go back to work, no one is going to say much of anything because: 1. They already know you are conscientious and learned whatever you needed to learn from this (which is nothing, because you're already conscientious. 2. You did all the right things. No one could have handled it better (no one did because someone could have spotted the missed med but didn't) 3. Nothing happened to the patient. Might have had a bit more urine output after the Lasix was resumed but but that's it.

We are not infallible. We do make mistakes. I see this thread is 4 days old so now the patient and you have survived this.

Ruby Vee, BSN · Mar 29, 2019

On 3/25/2019 at 11:28 PM, jeane1090 said:
Over the weekend I made a really silly mistake and I have been so anxious and upset ever since. Due to my anxiety and wanting to be a thorough nurse I always review my MAR at least once every hour, sometimes even more if I have time to kill. Somehow, even through my consistent checks, I missed a 0600 dose. I had this patient for night shift on Thursday and Friday night. On Saturday morning I was reviewing my MAR and went to administer the patients medication of lasix 80mg PO BID. I then realized that I had completely overlooked this medication somehow the previous morning so it was not administered. I filled out an occurrence report and called the doctor on call. The patient was fine but I am so upset at myself for this mistake. At this point I feel numb because it is all I have been thinking about for the last 3 days. I am terrified to go back to work even though I want to so badly.

Everyone makes mistakes -- everyone. We are all human and humans make mistakes. What matters is not whether or not you ever make a mistake, but what you do after you've made one. You called the doctor, filled out an occurrence report and no doubt are beating yourself up over this. You've done the right things. Now the thing to do is work on forgiving yourself.

I would much rather work with (or be cared for) by the nurse who has made a mistake and done the right thing than the nurse who insists she never makes mistakes. That nurse would never admit to making one.