Published Jun 24, 2005
THOSE THAT NEVER MADE A MISTAKE NEVER MADE A DISCOVERY!
I had a med error today, never completed the second checks from the previous shift and gave a Resident too much insulin. I definately learned a valuable lesson that I need to double check every new order that is recieved from previous shifts. Luckily the Resident is okay. Family was a upset but realized that we nurses are not robots but human beings after all.
It's so easy to do with just a little distraction. I nearly made a bad mistake today. My nursing manager was speaking to me as I was passing out 0800's today. She was asking me if I needed any help. Just in that small distraction, I was pouring about 10 meds for this one resident (a lot for one resident!) and when I went to give it immediately afterwards, I went to the wrong resident. She swallowed one tablet and had another in her mouth before I suddenly realised the meds were not hers! Fortunately, she hadn't yet swallowed the one in her mouth and was able to spit it out whole. I had to go back to the MAR and the medcart and check which one she had swallowed. She had swallowed a Multivitamin which she also gets at 0800. That was a close close call, there were enough strange meds in that pile that would have been a serious med error. It can happen to any nurse. But a med error like yours can always be a pivotal lesson and turn into a positive where you can learn and move on, and improve your nursing practice. Be well.
That is so very true - and a very constructive way to look at things. For every mistake I have ever made, I have forced myself to analyze the lesson learned, and taken steps in my practice to prevent the same thing from ever happening again.
I work in a LTC facility . The last 2 days I worked I found a med error each day . The first one wasn't too drastic but none the less a med error. The doctor faxed an order for a multivit , the paper that was recieved in the fax machine was laid with a bunch of other papers and was not taken care of . For 14 days ! The nurse that was on duty that night 3-11 shift did not take care of the fax when she recieved it and the it was "lost " in the other paper work .
The next day , the same nurse was working 3-11 so when I followed her it was 7-3 the following day . I found a syringe of insulin laying in the drawer of the med cart . It was in a specific residents drawer. I asked this resident - alert and oriented - if she had recieved her insulin last night and she stated " Come to think of it no I didn't ." This med error could have had a negative outcome . As it was the residents fsgs was 168 on this morning so everything turned out ok. I did alert the DON on both occasions , she then wrote out a memo about not setting up meds prior to giving them to the residents. I did fill out a med error report . When this nurse saw the memo she asked about it and I told her that I had found the insulin in the drawer . Guess what she said " Well last night I gave her insulin . I know that she had it . "
Well it's a different dose than is ordered for the 6 am dose so I know that she didn't get it . But I'm letting the DON take care of it . I did my part by reporting it and filling out the med error and notifying the doctor . I feel that I did the right thing . Now this nurse is upset with me .
Antikigirl, ASN, RN
We had an instance where a nurse gave regular insulin instead of her evening lantus...it was 60 units so quite a bit! Lucky no bad outcome, but ouch..what a mistake!
So instead of being "doh nurse..pay attention" about it...I was proactive! I grabbed all the lantus bottles and marked the boxes in yellow, and a yellow sticker on the bottom of the vials, regular is red, NPH is blue. This soooooo helped us out! Another check in the checks and balances that is easy to figure out :).
The only med error I made was long ago...and I don't consider it one at all! I had a patient who needed some normal saline IV, and I adjusted the rate and came back in 15minutes later to double check..the IV bag was 1/2 empty..the patient moved their arm during sleep and it was totally open then! Lucky for me it was a younger person, and it was only 15 minutes...I called the MD who didn't seem to mind this at all, we reset the rate, and I watched the pt like a hawk for any arm position changes...
A day later I had a med error form and a very angry charge nurse! I mean come on! Can't help position changes, that is why I always check back in! Lucky I charted everything that occured and said.."okay if this happens did I do everything correctly???" She agreed and we didn't fill out the form! These things happen, but lucky I double checked my patient and found it out quickly! Uhggggg!
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