Medication error

witnurse · Apr 7, 2005

Witnurse,
If you've only made 3 mistakes in 30 years then you are an EXCEPTIONAL NURSE!:)

:) Thank you. But as I said those are the ones I am aware of. It has been a difficult soul searching time with each one of them. I really hope we don't go back to PUNISHMENT mode unless it is a performance issue, where someone is repeatedly making mistakes out of carelessness or lack of training.

Trauma Columnist · Apr 7, 2005

I guess my question is why is an unlicensed person passing meds? I wouldn't blame this STUDENT - I would put the blame squarely on the person or organization that told her to pass meds!

stidget99 · Apr 7, 2005

Lesson learned.....again and again and again (as many times as you kick yourself). However, you have to get to the point where you can forgive yourself and continue being the absolute best nurse that you can be. Do so knowing that you are human and are prone to make mistakes. And I can guarantee that you WILL make other horrible mistakes. The secret here is to learn from each event.

The advice that previous posters have offered are all excellent. Let me add my two cents worth....

For those pts who are A&O ... get into the habit of asking them what their name is and not "Is your name Mrs. Jones?" For those who are not A&O and you are depending on an aide to identify a pt, do the same thing...ask them "What is this person's name?" for the same reason. With doing this, in addition to doing all of the other usual checks, you will be able to avoid similar mistakes in the future.

It is my personal belief that complacency is responsible for 99% of errors. Sometimes, during the course of our jobs, we tend to get complacent. You can ask an aide is this pt Mrs. Jones? And s/he, might answer yes, w/out even thinking about their response or the consequences by answering wrongly! Or a pt might not have heard you properly.

I also learned this the hard way when I was a new grad. I gave a non-verbal autistically challenged person someone else's meds. I made the mistake of asking "Is this Dennis W?" And the aide answered yes without thinking. Wham! Bamm! I gave this young boy a fistful of cardiac meds. I could have just died! I felt so terrible. Roy didn't suffer any acute or long term problems but it didn't make me feel better. I still, to this day, regret that mistake. But I learned my lesson. Now, when passing meds, I always ask pts to identify themselves in addition to the usual checking the arm bands.

Good luck to you. In time, you will forgive yourself. And please, anyone who can get through nursing school is NOT too stupid to be a nurse. Hugs to you!

live4today, RN · Apr 7, 2005

One of the major problems with long term care facilities is they don't require better identification of the residents because they don't wear ID bands on their arms. Their pictures all look the same to me, and many of the residents don't know their names, and if they do, they often won't tell you. Passing meds on twenty or more patients from just looking at a snapshot of them is totally not foolproof.

Don't beat yourself up over what happened. It happens to many nurses. :)

NoCrumping · Apr 7, 2005

I guess my question is why is an unlicensed person passing meds? I wouldn't blame this STUDENT - I would put the blame squarely on the person or organization that told her to pass meds!

What are you talking about? All nursing students give meds.... I was giving IV meds second semester of my first year. I gave PO meds the second DAY of nursing school......Did you have an opportunity to give meds as a student? If not, I wonder where you went to school....... :uhoh3:

ARNPsomeday · Apr 7, 2005

What are you talking about? All nursing students give meds.... I was giving IV meds second semester of my first year. I gave PO meds the second DAY of nursing school......Did you have an opportunity to give meds as a student? If not, I wonder where you went to school.......

I just finished my second semester clinicals on a telemetry/ med-surg floor. In the beginning, we were not allowed to give meds. As the RNs got to know us, we began doing it in their presence (or our clinical instructor, an RN), and then some allowed us to do it on our own. It is a assumed risk. They relied on their own judgment of our capability.

ButterflyRN04 · Apr 9, 2005

We all make mistakes. Take your time when giving meds, even if the med is late. I've made med errors myself that I know I will never do again. Don't feel stupid, just be more aware.

NoCrumping · Apr 12, 2005

I just finished my second semester clinicals on a telemetry/ med-surg floor. In the beginning, we were not allowed to give meds. As the RNs got to know us, we began doing it in their presence (or our clinical instructor, an RN), and then some allowed us to do it on our own. It is a assumed risk. They relied on their own judgment of our capability.

I guess its different in all schools.... I went to a diploma hospital based program, and our instructors, not the RNs on the unit that day, dictated what we will do and when. The students and our instructors took full responsibility for the patients we were assigned to. We went in the day before for our assignment, did full research on meds, dx, everything, and had to be fluent in all things pertaining to out patients, and we were quizzed verbally throughout the day. It was a structured program, like po meds, 1st semester, iv 2nd semester.... the floor RN's had no say, and no risk was assumed by them as we were working under our instructors license. They loved us, because that meant one or two less patients in their assignment.

EDNURSEANGEL · Apr 12, 2005

In my state an unliscensed person can not pass meds. We did in nursing school, but we worked under the liscense and and direct supervision of our instructor.

I worked as an intern (extern) when I was in school, and I would never have been allowed to give medications.

I am very sorry this has happened to you. But use this as an opportunity to learn from your mistakes. I wonder if you had already been a nurse if you would have been fired for a med error. It may be the facility just doing a little CYA.

Best of luck,

Angel :)

ariella · Apr 12, 2005

:Melody: I am thrilled to have stumbled on this site. I work in long term care-yeah, nursing home. Sometimes I feel like we are treated like the bottom rung of health care. We have a tremendous amount of meds to pass in a short time and it is commendable that we don't have more med errors. Today we had a med error discovered that affected 12 nurses. I felt most responsible because the med was given once a day and on my shift. Why did I not notice? Because the minute I walk thru the door I am hit from all sides with various duties. The worst of it is that I want to be a good nurse and become a better one but I stay too worn out to research anything. Today I had a situation where a patient had a critical lab-PT INR. I showed the lab to a senior coworker and then faxed the results to our Dr. I don't know why I did not call him then. About an hour later I called the Dr. and the pt was sent to ER. Everything turned out alright but it was just another time when I felt incredibly stupid. I think people in general regard nursing homes negatively. I hope the perspective changes because most of us in long term care are dedicated nurses.

Trauma Columnist · Apr 12, 2005

No Crumping - My interpretation of the OP was that she was doing a med pass without supervision. Again, this is essentially an unlicensed person performing a duty where a license is required (this is according to Illinois nurse practice act). I certainly don't put the blame on this nursing student - she was working (as she stated) not doing a clinical which is entirely different. It is the system that failed her.

As to where I went to nursing school - I came up through the ranks: LPN to ADN to BSN to MSN. And yes, I passed meds in clinical - however, the caveat here is that I was working under someone else's license and I was supervised.

SmilingBluEyes · Apr 12, 2005

No Crumping - My interpretation of the OP was that she was doing a med pass without supervision. Again, this is essentially an unlicensed person performing a duty where a license is required (this is according to Illinois nurse practice act). I certainly don't put the blame on this nursing student - she was working (as she stated) not doing a clinical which is entirely different. It is the system that failed her.
As to where I went to nursing school - I came up through the ranks: LPN to ADN to BSN to MSN. And yes, I passed meds in clinical - however, the caveat here is that I was working under someone else's license and I was supervised.

absolutely right. (((Kittiesrus))) Like Tweety said, try to learn from this and forgive yourself.