My First Big Mistake

[chevyv, BSN, RN]

I've been a RN for about 1 yr now. I'm the only RN working on my unit. This is normal. The other night I had a very violent pt so I had to call the doc to request a prn. I was on hold for a long time so I started charting my nurses note while still keeping tabs on my pt with Security battling. Doc comes on the line and I ask for a certain med IM, get the order and the doc adds to the order. I gave name, DOB, etc but totally forgot allergies! Of course the one med is listed in the allergies, which I didn't check. As soon as I gave the meds, I had a feeling. I immediately checked the chart and saw the med listed under allergies. I was horrified and called the doc stat. Gave IM of Benedryl and all was fine, except for me. How could I have made such a stupid error!

I've learned so much from this mistake. No matter what is going on around me, I have to make sure to stay focused on what I need to. I care so much for my patients and this was awful. Turns out there was no allergy, but doesn't matter because it was listed and I didn't check. We have no computer charting, all paper.

I would love to be able to say allergies are listed in some obscure place, but they aren't. They are in bold letters on each physician order sheet, on the cover of the chart, and in the MAR's. I was writing a progress note (the only place where allergies aren't listed) and was in a hurry once I got the order. I will never make this mistake ever again.

I'm writing this for 2 reasons; the first is because I still feel awful and the 2nd is that even though I feel so awful and ashamed, if this helps one nurse to not make the same mistake, I will be grateful. This is my first huge mistake and boy is it a big one!

[Davey Do]

Good for you, chevyv! You did everything right after making your mistake: Identified the error, did something about it, and went on to make it a learning experience. To err is human, but to be able to gain something from the experience is sublime!

[HeatherPsychRN]

:lvan::lvan::lvan::lvan:Thanks for sharing this. At my old job, they had what was called a "near miss" for when at any point prior to giving or doing something for a pt was found to be incorrect, you would treat it as it were a medical mistake, but just the hospitals use that info to improve and educate others whenever possible. I am glad the pt only needed a dose of benadryl.

If we all post and read these things, then you can help others for sure. I can tell you that walking into my third orientation class for my new adolescent phych rn position, I will be remembering to check those allergies!!! Hmmm... Maybe I will adapt the SBAR to include for me the allergies... :lvan:

Thanks again...

Heather

[Simply Complicated]

Thanks for sharing! I almost made the same mistake a few weeks ago, and sad to say I was not the one who caught it. It was the other nurse working with me. Although had I been the one scanning the meds I would have. Luckily I refuse to give a shot before it's scanned into the system. We got an order from the doc, pulled it and drew it up. I waited to go administer it, while she scanned the meds in. Security was getting on me to give the shot, thank god I waited. This was an actual allergy to the Haldol the MD ordered.

This just reinforces that we are all human, and at times we are in a rush we need to remind ourselves to slow down and take the time to do things the proper way!

[Whispera, MSN, RN]

We certainly are all human. Bet you a nickel you'll never, ever, make that mistake again. You've learned from it, right? Maybe it happened to give you a learning moment?