Medication Error..total sadface : (

[NightNurse876]

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 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

[biblepoet]

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 You really have to be vigilant all the time.

It happens. It stinks. We are human.

I tip my instructor told us in nursing school is to mark on the item in sharpy the dose you need so you do not make a mistake on it. Works well. But do not beat yourself up for the mistake. Just vow not to do that one again. We are all human and mistakes happen. Glad nothing serious happened to the pt. because of this.

[leslie :-D]

accountability is a biggie in nsg.

in nsg school, i never truly understoody why our instructors kept on emphasizing that...

until i gave my pt 10x amt of morphine that was ordered.

i wanted to give it all up, right there and then.

no harm to pt...rather, md ended up increasing the 10mg to 60mg, with increase in prn's.

still, i had nightmares for months.

accountability.

it's the only way we grow.

leslie

[rnlately]

Not making light of the situation but many nurses have made the exact same mistake; and yes it is something to be taken seriously but not to the point that you continue to beat yourself up. If anything, I'm sure this event has/will cause you to be more cautious and aware (take it from someone who's been there). You are a better nurse because you admitted to it and didn't sweep it under the rug. Best wishes in your career.

[OttawaRPN]

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.

This isn't true. Benzos in particular can make the elderly downright loopy. Often my elder patients will only have an order for 0.5 - 1 mg max. Besides it doesn't matter if the 2 mgs made a difference to this patient or not - a med error is a med error.

I wonder why the preceptor hasn't taken her portion of the blame in the OPs situation; she had no business handing her student the med - she should have retrieved it herself.