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Medication error wrong patient

Posted

Hi Everyone,

I feel horrible I made my first medication error this week. I’ve been a nurse for about 3 years. I read the order and administered the medication to the incorrect patient. I filled out an incident report, spoke with the doctor and patient and sent an email to my manager. No harm came to the patient. I’m so upset and struggling to wait for a reply. Any stories to help me feel better while I wait.

Sour Lemon

Has 9 years experience.

I've made a huge, but harmless, medication error and still remember how horribly lonely I felt afterwards. People tend to avoid sharing their own stories, probably because they're embarrassed or just don't want to relive them.

I hope that you are treated as well as I was when it happened to me ...and that you learn from it, of course. It will take a while for the shaky feeling to go away, unfortunately- even under the best possible circumstances. 🌼

BSNbeDONE, ASN, BSN, LPN, RN

Specializes in Med/Surg, LTACH, LTC, Home Health. Has 35 years experience.

I made a medication error back in 2002. The patient wanted something for nausea. She had Phenergan ordered; I gave her Morphine. Back in those days, both of these drugs were in a 25-vial carton. We had to count and sign out each one. I’d done this so much that I could do it in my sleep...or so I thought.

That particular day as I was reaching for the Phenergan, another nurse burst into the drug room and startled me. I picked up the wrong carton, pulled the vial, signed out the drug, and gave it. I was still so shaken (and rushed) that obviously I didn’t do the required checks before giving the med. My patient went off to dreamland.

I called the doctor after we traced the med discrepancy back to me. He said, “I bet she feels really good now”. I said, “yes, and she said to ask you if she can have some more of that”. Of course the answer was a hilariously laughable “No”!

I may have had other little embarrassing hiccups over the years; after all, I’m only human. But I guarantee you, I never made that or any other medication mistake again! I’ll just bet it’ll be many years before you make your same mistake again, too. Your managers have all been there at least once in their careers.

You are amongst friends and/or friends to be.😉

I've done it. Gave 0.25mg Ativan to LOL#1 in hall bed A instead of LOL#2 in hall bed B. Turns out radiology had both the patients at the same time and switched their gurneys when they returned them. My fault for not checking armbands but also system error because post-it notes on walls aren't EBP for identifying bed spots in over-crowded EDs. My physician covered me with an order, shouldn't have but this was a lonnggg time ago.

Also wanted to say, you'll be fine. You aren't a terrible nurse. You will probably make more mistakes throughout your career but I bet you never make this one again. 🤗

sirI, MSN, APRN, NP

Specializes in Education, FP, LNC, Forensics, ED, OB. Has 30 years experience.

I've done it as well. Many of us have.

My story ... I had been a Nurse for maybe a year.

I was Charge for 2 different units. That night, I was back in one unit.

A nurse from the other unit approached me that physician had ordered a drug STAT (no route designated) for a LOL. She said pt. had been vomiting constantly and couldn't hold anything down so asked me should she just go ahead and give the med IM. I told her that would be fine. She gave it.

Well, that certain drug is never to be administered IM, only PO or sub-q. I didn't know that because I was not really familiar with the drug ... no, honestly, I didn't know anything about the drug.

Everything turned out o.k. in the end. It was a very long night.

I learned an extremely valuable lesson. Never, EVER, administer a drug w/o knowing everything about the drug and the rights of administration.

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine. Has 8 years experience.

As someone wisely said not long ago on this very forum, there are two kinds of nurses: those who did medical error at least once and those who didn't do it yet.

I did exactly that once as a nurse and one more time as NP student. Gave a DTaP shot to a wrong kiddo out of like 3 or 4 who were running around the office. I seriously though my destiny was sealed, and not for good. What a surprise it was when the mother found me in a couple of months or so and was besides herself with appreciation - that older kid had direct pertussis contact "face to face" with his several sleepover mates getting it, but he didn't have a touch 🙂

Edited by KatieMI

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine. Has 8 years experience.

7 minutes ago, sirI said:

I've done it as well. Many of us have.

My story ... I had been a Nurse for maybe a year.

I was Charge for 2 different units. That night, I was back in one unit.

A nurse from the other unit approached me that physician had ordered a drug STAT (no route designated) for a LOL. She said pt. had been vomiting constantly and couldn't hold anything down so asked me should she just go ahead and give the med IM. I told her that would be fine. She gave it.

Well, that certain drug is never to be administered IM, only PO or sub-q. I didn't know that because I was not really familiar with the drug ... no, honestly, I didn't know anything about the drug.

Everything turned out o.k. in the end. It was a very long night.

I learned an extremely valuable lesson. Never, EVER, administer a drug w/o knowing everything about the drug and the rights of administration.

Well, if you administer something IM, unless your patient has low fat index (practically, a young athlete or underweight/cachectic) or if you go gluteal, quite a high % actually end up as SQ. I saw number of 75% for gluteal. So, you did it all right after all. If it can make you feeling better about yourself 🙂

Someone told me a long time ago that if you hear any nurse bragging that she's never made a medication error she's either lying or just too stupid to know the difference.

Mistakes happen. Haven't ever, not ever, met a nurse who wasn't a shiny bright new grad (meaning no time on the job yet) who hadn't made one. Once you experience that anguish, it definitely makes you more careful moving forward you can bet!

lexotaNIL, BSN

Specializes in intensive care unit. Has 11 years experience.

when I was assigned in ER I had 2 times medication error. dexamethasone for pedia but I gave Dansetron. the other one was I gave the loading dose of plavix for the wrong patient. Good thing both of them are safe. if you were never done any error that is a big lie.. hahaha.

Well, here’s mine for you. I was giving an expensive anti rejection IV medication and thought the tubing was connected to the main IV and when I opened the clamp, a few thousand dollars of medication ended up on the floor. Yup. It happens and in time you’ll put it behind you. But you won’t forget it and it will make you a nurse ❤️