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Discussion

My Bad.

As a student and new nurse I recall seeing certain errors made and thinking, "Nope, not me." I am a cautious person. I check and double check. I don't take anyone's word for it. I assess every patient every time.

So imagine my surprise on the day I gave a medication without a physician's order.

Really, I shouldn't have been surprised, I knew better.

I was handed a syringe and asked to assess and medicate a patient I was familiar with. It was urgent, the primary RN told me she had a PRN order, I knew the patient had been receiving the med.

I thought "I should check the last dose" but time was a factor, so I went against my instincts, pushed my OCD aside and went to the patient, assessed and gave the med.

I returned to log off the med and oops! the order was for a one-time dose, which had already been given.

My co-workers laughed: "Dr. A will cover you"

Dr. A laughed: "of course I'll cover you"

I didn't laugh. I know that the patient needed the med, I know that no harm came of this, but it brought me up short.

I am so used to the team atmosphere that I forgot an important lesson, it's my butt, so I had better be sure I'm the one to cover it. I don't ever want to be in a situation where I need someone else to perform that function for me again.

So lesson learned. On that day, it was me. I'm not immune, because, even when you *always* do something right, all it takes is once to do it wrong.

I think this is important for all us nurses to keep in mind, especially as we get further away from the nerves of entry to practice and into the confidence of experience.

All it takes is once.

Don't get cocky.

So here's to my good luck and my resolution never to need it again.

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    It happens to all of us at one time or another. Thanks for sharing this reminder.

    Another reminder, remember to always label your syringes (or in this case, the nurse who handed it to you should have). I hate to also be put in the position of being handed unlabeled syringes of whatever, and do and will say "you need to give this, as you drew it up".

    One of the worst parts of nursing is to be in the hot seat and put in that postion. ESPECIALLY for the type A personalitly. (Of which, I am guilty as charged!)

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    Thanks! The label thing is important too!

    In this case the med was labeled appropriately, and I do truly trust the Nurse who drew it up/asked me to give it, but that's the point. We can all mess up and it doesn't hurt to double check.

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    Depending exactly on what it was and the circumstances, if they need it emergently, then give it. Get the order after. Of course, if you've got time, most certainly call FIRST!

    "Mr. Jones was throwing up again and I didn't want him to rip his sutures out, so I gave him an extra dose of Zofran. Can I have a PRN for Zofran so you don't have to be called at night?" "Sure, that's fine. Zofran 4mg, IV, Q6h PRN and also 10mg Reglan IV, Q6h PRN for nausea. Also, if he continues to be nauseous, sink an NG to LIS and get a KUB in the morning."

    Thanks Dr. A ! ;)

    :roflmao:

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    We all need a reminder like this. Thanks!

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    ESPECIALLY for the type A personalitly. (Of which, I am guilty as charged!)

    Oh wait. Is that not a prerequisite? Maybe I'm getting into the wrong career...

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    What was the med? Why couldn't you draw it up yourself with supervision? I don't care to give anything that someone else has drawn up, no matter how much I trust them. Maybe I've lived too long and seen too much? :yes:

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    In school they drummed it into our heads that we were never to give meds drawn up by someone else; when I was orienting on my current job, I refused to give meds drawn up even by my preceptor unless I watched her get the med out of the cart and draw it up. There is a reason I have a reputation for being AR. Anyway, this is a great reminder! It's also a good reminder to use whatever safety checks your institution has; I really try never, ever to give a med without scanning it first, even if I know good and well that they can have it. Some places don't use bar codes, though, and this type of mistake is easier to make.

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    • Author
    What was the med? Why couldn't you draw it up yourself with supervision? I don't care to give anything that someone else has drawn up no matter how much I trust them. Maybe I've lived too long and seen too much? :yes:[/quote']

    I think you may misunderstand the situation a tad bit. I am an RN and do not require supervision to draw up meds. The RN in question was busy with another emergent task, with the patient in question and again, time was a factor, the med was already drawn up with appropriate labeling, I have no doubt that I gave the med I intended to give, and that it was appropriate for the pts condition. I had also given a prior dose of the medication to this patient with a physician's order.

    The reality of my workplace is that in some scenarios we do give meds drawn up by another nurse. It's not ideal, but it happens. If I'm maintaining airway and suctioning my seizing patient my coworkers will have no problem picking up my pre-drawn syringe of Ativan and using it, and I will do the same for them, we are a team.

    My error in this scenario was not double checking my MAR for a valid physician's order.

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    • Author
    In school they drummed it into our heads that we were never to give meds drawn up by someone else; when I was orienting on my current job I refused to give meds drawn up even by my preceptor unless I watched her get the med out of the cart and draw it up. There is a reason I have a reputation for being AR. Anyway, this is a great reminder! It's also a good reminder to use whatever safety checks your institution has; I really try never, ever to give a med without scanning it first, even if I know good and well that they can have it. Some places don't use bar codes, though, and this type of mistake is easier to make.[/quote']

    Totally agree with you on the safety measures, although we don't have a scanning system it is a manual check and old school sign off.

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    If I have to predraw meds, and may have to get someone else to give them, I tape the vial to the syringe. Then everyone knows exactly whats in there.

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