Mistakes held against you

I made an error that I didn't report until a day or two after. We had this long term antepartum patient and our docs were routinely ordering 10 mg of Ambien every night for sleep. I had taken care of this patient for so long and every night she got 10 mg Ambien. One routine night I walked in and gave her her 10 mg Ambien. After she swallowed the pill she asked me how much I gave her, she said the doctor changed the order that day to 5 mg Ambien because she c/o hallucinations. WHAT??? :smackingf Why would she ask me what i'm giving her after she swallowed it? I know its my fault for not seeing the order. I called the doctor and let him know, he was fine with it. I left it at that, the next night another nurse made the exact same mistake and she reported it. So I guess I thought since he was fine with it I didn't have to report it, but when I found out another nurse reported it, I realized it only made sense to do so as well. DUH! it was a med error.

Report it, report it, report it! It should not be held against you, it should be used as a learning tool for you and for other staff. We are human and mistakes happen, every day, all over the world. Mistakes are made by brand new nurses and nurses with years of experience. Hiding them only makes it worse, it eats away at you, it has the possibility of repeating and it could turn into a cycle of mistakes, causing real harm to someone. It could have happened because of lack of information, maybe it's a process problem, maybe it was related to laziness or becoming complacent to basic safety practices. Maybe it was just an error in judgement.

Bottom line.... REPORT IT!