Medication Error..total sadface : (

Nurses General Nursing

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So...I'm a new grad. First job...5th full shift with preceptor....1st freaking Med Error...always wanted to say never : ( but...there goes that hope. I was told it wasn't a big deal, but I feel horrible. I'm up to 3pts now and today I voted on doing the admission for a 4th pt (honestly I didn't want the 4th pt....wasn't 100% confident but I wanted to do the admission...so I think me and my precep's lines got crossed) So me, being the over achiever decided I would keep it moving. The pts meds took forever to become available and they were about to lose it if they didn't get something for anxiety...So here comes my precep with the ativan and I had just looked at the order and....since I was sure I checked it and I just admitted the pt I felt "on track." My med administration was wonderful, except for the part that I gave 2mg instead of 0.5mg :eek: Yes the pt was fine and was about 200lbs so it "didn't hurt" as I was told (I dont even think the 0.5 would've helped her much) I STILL FELT LIKE UTTER AND COMPLETE CRAP!! Never again!! My medpass strategy has just changed and become way more strict...but still...My director, manager and educator..as well as pharmacy with now raise an eyebrow at the new grad and her supid mistake...My precep told me I did great today balancing my pts and charting etc but I feel different. I feel that I didn't manage my time as well as I could have and if I would've checked the omicel myself I probably wouldve avoided the problem...this sucks...I feel horrible....really just want to curl up in a ball...and I work tomorrow....I just don't want it to affect my progress...if anything I want to improve how I medpass and what my strategy will be for PRNS, STATS, and such. I've always felt that I would make an excellent nurse...this feels like I just got 5 million demerits on my journey to awesomeness...Thanks for lending an internet ear AKA eyes and keyboards :o

Specializes in L&D.

You learned from it, and you didn't hurt anyone! Relax! You are indeed a great nurse already. At least you admitted that you made a mistake: some people have so much pride, that they can't! Who'da thunk it? :p

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Specializes in pulm/cardiology pcu, surgical onc.

It sucks to make an error the 1st time! It's too bad pharmacy didn't order it to be dispensed in 0.5 mg than that wouldn't have happened! I've learned to always take the unopened med to the bedside and do my last safety check before giving to the pt.

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0.5 mg of ativan makes no difference to anyone, and half the time neither does two mgs! I'm wondering why the omnicell/pyxis/etc. didn't alert you as to the correct dosage.

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Specializes in pulm/cardiology pcu, surgical onc.

Just curious OP, I'm not familiar with Omnicell but is it the same as Pyxis and will only open a drawer when there is an order and pharmacy controls what drawer (meds w diff strengths) open? To have to cut a pill in 1/4 is ridiculous and not good practice no matter what the med is.

Our pharmacy will always try to give us access to the correct dosage to cut down on waste and increase efficiency.

Actually 0.5 mg can be effective for some pts. I had a pt getting 2 mg and was getting aggressive/agitated. When cut back to 0.5 the pt was pleasant and calm.

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You never want to be cavalier and casual about making a med error. BUT, you also don't want to be so focused on beating yourself up that you take your eye off the ball and lose your concentration as you move forward.

I would also suggest that instead of trying to have a mistake-free career you do the next med correctly. And the next one. And the one after that. It's easier to handle when you take one step at a time.

Best wishes.

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A lesson learned...Don't beat yourself up (easier said than done)..We have all been there, the great nurses included!..As long as you have realized and learned a lesson from this you have a step up on so many other nurses.

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Specializes in Med/Surg.

I agree with what all the previous posters have said, learning from your mistake is the best thing you can do . I've made med errors, I don't know any nurse who has never made one. So now when I feel rushed at work, whether doing a med round or whatever, if things are piling up and I feel like I'm chasing my tail, I just say to myself...."I can only do one thing at a a time" and that allows me to focus more on what I'm doing.

You are a good nurse because you worry about this. It's the nurses who don't care who are the ones to worry about!!!

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Specializes in CCU, SICU, CVSICU, Precepting & Teaching.

everyone makes mistakes. everyone. i'm glad that you're not taking this in a cavalier manner, but this is only the first med error you will make in your career. there will be others. as long as you admit the error as soon as you recognize it and do what you can to mitigate the damage, patients will surprise you with their ability to shrug off mistakes.

what i'm wondering is where your preceptor was when you were administering the ativan. in our unit, preceptors watch every step of the process when an orientee gives a med, including doublechecking the dose. from the first clinical day right up until the last.

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who pulled the med from the omnicell, and how did they get the 2 mg instead of the 0.5?

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Thats right, 5 safety checks. Im sure every nurse has had them, some admit to them, some don't.

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Specializes in floor to ICU.
who pulled the med from the omnicell, and how did they get the 2 mg instead of the 0.5?

Our hospital only carries 2mg vials. Of course, you have to waste with someone before the med is dispensed so this is your first indicator (besides what the MAR and order says).

In tiny, tiny print in the same color as the rest of the writing at the bottom of the screen to the right it says: dose 0.5mg :rolleyes: You really have to be vigilant all the time.

It happens. It stinks. We are human.

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Specializes in pulm/cardiology pcu, surgical onc.

Her preceptor brought her the Ativan, maybe if she took it out herself than she would have noticed the dosage. It sounds like she was rushed and feeling pressured. Not a good combination to administer meds. Sometimes when I feel rushed I have to take a mental time out before giving meds.

I don't know if it was oral or IV but did the preceptor bring her the whole dose and where did the preceptor go?

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