3 medication errors in 7 months!

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I know, I know...most of you must be looking at this and thinking :eek: I'm living it and I feel the same way. I'm posting this because I really need some advice; I'm depressed, confused, feeling incredibly stupid and very guilty. Let me give you the scenarios and you can tell me what you all think. By the way, in case you can't tell...I'm a new grad, June 2005:

1) First medication error occured when I gave the wrong patient the wrong medication (I did a stupid thing by carrying two patients meds at the same time). This patient happened to be a chronic pain patient, knew the medication wasn't for him but accepted the medication anyway. The medication was Percocet 5/325. I alerted my charge nurse right away, told the doctor (who started laughing and told me not to worry about it because this patient was on so many meds the percocet wouldn't do anything to him.), and wrote out the incident report. Went home that day feeling terrible and wondering if I'm really going to be good at this. :o

2) Second error: received report from Step-down unit, was told this patient had not received his evening dose of Coumadin. When this patient came up to the floor I looked in his file to see if the Coumadin had been given, couldn't find the documentation in the usual place, called the nurse back in an attempt to find out whether it had been given or not, later found out I was connected to another nurse who had also given me report that same night and who told me she had not given the Coumadin. Gave the patient 5mg Coumadin and then found out the original nurse had already given the 5mg!!! Once again filled the incident report and once again went home feeling terrible and wondering if I made the right decision to be a nurse. :o

3) Latest one: Received report from one of the nurse on my floor that the patients Unasym had been discontinued and the patient now had an order for Penicillin Q24hr, when I looked in the MAR I saw the registrar had picked up the order as Q24hr also, I signed off in the patients chart right under the registrars signature. To make a long story short, next day received a call from the charge nurse on days alerting me to the fact that the patient had missed 3 doses of her penicillin because it was ordered for Q4h!! Filled out another incident report, was written up for this latest occurence, went home and cried myself to sleep and have been feeling horrible ever since. :o :o

For the past 20 years all I've wanted and dreamed about was becoming a registered nurse, I graduated at the very top of my class, received the Gold medal at graduation, and am was hired at one of the top orthopedic facilities (which has Magnet status) in the nation right out of school. I can't help but wonder...what has gone wrong? :uhoh3: I can honestly say, I've learned from each and every incident, but I'm beginning to wonder if I should quit before I'm fired. :crying2:

Any and all advice will be very much appreciated. Thanks.

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Specializes in ED, ICU, PACU.
I know, I know...most of you must be looking at this and thinking :eek: I'm living it and I feel the same way. I'm posting this because I really need some advice; I'm depressed, confused, feeling incredibly stupid and very guilty. Let me give you the scenarios and you can tell me what you all think. By the way, in case you can't tell...I'm a new grad, June 2005:

1) First medication error occured when I gave the wrong patient the wrong medication (I did a stupid thing by carrying two patients meds at the same time). This patient happened to be a chronic pain patient, knew the medication wasn't for him but accepted the medication anyway. The medication was Percocet 5/325. I alerted my charge nurse right away, told the doctor (who started laughing and told me not to worry about it because this patient was on so many meds the percocet wouldn't do anything to him.), and wrote out the incident report. Went home that day feeling terrible and wondering if I'm really going to be good at this. :o

2) Second error: received report from Step-down unit, was told this patient had not received his evening dose of Coumadin. When this patient came up to the floor I looked in his file to see if the Coumadin had been given, couldn't find the documentation in the usual place, called the nurse back in an attempt to find out whether it had been given or not, later found out I was connected to another nurse who had also given me report that same night and who told me she had not given the Coumadin. Gave the patient 5mg Coumadin and then found out the original nurse had already given the 5mg!!! Once again filled the incident report and once again went home feeling terrible and wondering if I made the right decision to be a nurse. :o

3) Latest one: Received report from one of the nurse on my floor that the patients Unasym had been discontinued and the patient now had an order for Penicillin Q24hr, when I looked in the MAR I saw the registrar had picked up the order as Q24hr also, I signed off in the patients chart right under the registrars signature. To make a long story short, next day received a call from the charge nurse on days alerting me to the fact that the patient had missed 3 doses of her penicillin because it was ordered for Q4h!! Filled out another incident report, was written up for this latest occurence, went home and cried myself to sleep and have been feeling horrible ever since. :o :o

For the past 20 years all I've wanted and dreamed about was becoming a registered nurse, I graduated at the very top of my class, received the Gold medal at graduation, and am was hired at one of the top orthopedic facilities (which has Magnet status) in the nation right out of school. I can't help but wonder...what has gone wrong? :uhoh3: I can honestly say, I've learned from each and every incident, but I'm beginning to wonder if I should quit before I'm fired. :crying2:

Any and all advice will be very much appreciated. Thanks.

I remember reading that the OIG concluded that the majority of med errors were procedural faults rather than that of the nurse. What you have described reminded me of this because #1 was done because of the procedure you followed which permitted you to carry meds for more than one pt at a time, #2 in that there was no identifiable procedure in place to definitively record that a pt had or hadn't been given a med by someone else and with # 3 because there was no procedure to verify ambigious orders even existed and that a prior nurse should have been the one to sign off the orders if they were given to you in report. I really think that the institution you work for has to develop some policy and guidelines to avoid incidents like this, rather than have you believe that you are doing your job poorly. Only #1 was a truly avoidable incident because you had control over the situation. As for the other 2, you seemed to have done your job correctly and being penalized unjustly. Hope everything works out for you.

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I know you are feeling rotten, and nothing is going to change that. What strikes me, though, is that you are not making excuses. You are instead blaming yourself exclusively, and you should not do that. Yes, #1 was your fault, but you have learned from it. The other two should not be blamed on you. It sounds to me that you checked everything you are supposed to check. I hope you don't let this dishearten you. This profession needs more nurses like you who hold themselves to such high standards.

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Well it seems like #2 wasnt your fault. And you probably could have gotten a one time order from the doctor for the first one to cover yourself. Number 3 I'm not sure about. Seems like a transcription error.

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Specializes in Nephrology, Cardiology, ER, ICU.

First congrats on becoming an RN. Your first year of being out on your own is very hard. Hopefully you have learned from your mistakes and can go on. The best piece of advice I can give is to learn from your mistakes, vow not to repeat them, take a deep breath before giving meds and go forward.

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Take a deep breath

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Specializes in Critical Care.

Mistake #1 has more than likely happened to most if not all of us at one time or another. You know what happened and can now prevent if from happening again.

Mistake #2 sounds like you did everything you could to make sure the med wasn't given before you gave it. You can only go on you verify, you're not psychic ( I don' think anyway). The only thing I would say you could do was ask the patient. I know that a lot of the time that can't be a perfect solution as some of our patients are confused, but short of that I don't see how that error can be chalked up to you. It seems like the previous nurse should be at fault for not charting the med.

Mistake #3 is a 50/50 thing. You should have verified the order for the medication before signing it off and giving it. Even in these days of automated order entry and all, I would still check out the order myself. After all, it's your license and a triple-check never hurt anyone and has saved quite a few mistakes from being made.

Learn from your mistakes. They happen to everyone, even those people who profess to be perfect. Don't beat yourself up because that is going to make you fearful of making another mistake and may even make it so you make more.

Good luck and keep your chin up.

tvccrn

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I had a charge nurse come in and made a med error on one of my patients right at the start of the shift, personally, I think alot of med errors aren't reported.

JMO.

But you'll do fine. Good luck

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Thank you all so much for your support. The saying goes "Hind sight is 20 20", so obviously I now know where I went wrong with these errors and I never plan on making them again. I've been unhappy in this job pretty much since day one and I absolutely hate working 3rd shift (I've always been a day person), but the charge nurse on my shift and my coworkers have all been really great so I guess that's what has helped me to hold on for seven months. But I'm finally realizing that I'm exhausted (working nights, taking care of a home, husband and two kids), I'm depressed, I've lost the little bit of confidence I had when I graduated from school and I think it's time to start looking for a day position somewhere else. Once again, THANK YOU!!!!!

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Specializes in med surg.

Hey quit knocking yourself. Think of the bright side--no one died!! Also, remember we nurses are human too so don't let it get you too down. I once gave hydromorphone 2mg instead of morphine 2mg because I was rushing and didn't read the label just grabbed the purple label!! My error and you learn from your mistakes.

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everyone is right. Sometimes it is the SYSTEM, not the NURSE that is faulty. there are alot of things wrong with the system, and unfortunately everything seems to fall on nurses.

You sound like a great nurse. chalk them up and move forward, being aware of glitches in the system.

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I remember reading that the OIG concluded that the majority of med errors were procedural faults rather than that of the nurse. What you have described reminded me of this because #1 was done because of the procedure you followed which permitted you to carry meds for more than one pt at a time, #2 in that there was no identifiable procedure in place to definitively record that a pt had or hadn't been given a med by someone else and with # 3 because there was no procedure to verify ambigious orders even existed and that a prior nurse should have been the one to sign off the orders if they were given to you in report. I really think that the institution you work for has to develop some policy and guidelines to avoid incidents like this, rather than have you believe that you are doing your job poorly. Only #1 was a truly avoidable incident because you had control over the situation. As for the other 2, you seemed to have done your job correctly and being penalized unjustly. Hope everything works out for you.
Excellent post. I certainly hope this hospital uses these incidents to rectify the system errors that allowed them to occur in the first place.
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