My First Med Error

[Bellarn80]

Hi Everyone Im new to this site but so happy it exists. Ive been working as a new RN for a few months now and Im on orientation working the 11-7 shift. I have a patient that has prn narcs. Its the same narc but one its liquid and other is tablet. The liquid does is 2.5ml/5mg and the tablet is 5mg. This patient was in pain so I looked on her EMAR and saw both options. I chose the liquid because she's 93 years old and it was at 3am. I gave it to her, marked it in EMAR and wrote down in narc book. On our shift I we do 24checks in the patients file. No new orders were put in and no D/C orders were written in. So I went ahead and gave it. The morning came and during report I mentioned that the patient doesn't speak English but by her facial grimaces you can tell she's in pain. The Nurse said, yes her son was in saying that we weren't medicating his mom. I then mention what I gave and what time. The supervisor came and overheard conversation and said she had D/C'd the liquid form at 10pm. My shift was 11-7. I said I looked in the chart and there were no new orders nor D/C'd orders. I showed her the patients file and she then went to her office and grabbed the orders that she did including the D/C'd one. I said it was on my EMAR. She told me that was impossible and I was tired, Which I was no sleep in 3 days, but I was alert and new exactly what I was doing.The supervisor then said to go to her office and she was kind and said I made a med error and that she too made an error by forgetting to put the DC'd order in the file because I would have seen it and instead of giving liquid I would have given tablet. Anyway, I was asked to stay and another supervisor got involved, etc. Everyone made me feel so stupid and this was the end of the world. I didn't get out until 11:30am. I began to cry as I was leaving and our NPE saw me and said to go to her office to talk. She asked what happened and I told her. She went on EMAR to look at something and said wait, she called IT and for the first time they realized there was a glitch in the system. It did show up on my EMAR since the supervisor DC'd it at 10pm my shift is 2300-700. It wasn't enough time to actually remove it from my EMAR. She called The DON and explained the situation and the DON said that I wasn't going to get written up because I did everything right. I looked in the chart and no new or D?C'd ordered, it was on my EMAR and none passed it along in report, but I feel terrible for my supervisor because she's a sweetheart and just became unit manger. Im returning tonight and so worried what everyone will think of me now. While this was being said RN's were saying it couldn't be on your EMAR, see.. Once it's D/C'd it no longer shows up and that I need to be more careful and not assume a med I gave the night before was still available. No one believed me but NPE took time out to get to the bottom of why I saw it. Im grateful she did that because I began to second guess myself. Im feeling absolutely terrible for this entire situation and it makes me want to quit and think Im not a good RN.

The patient was fine because the tablet was still a prn, same does. What they did was change her 2 narcs instead of prn they made the 5mg q6 hrs. What should I do when I go in tonight and have to face the one RN that's been there 20years and spoke to me like I was a 5 year old. BTW whenever she was suppose to be orienting me she would say she didn't like to and for me to take one wing and she would take the other wing.

[HouTx, BSN, MSN, EdD]

OK - I get the gist.... in the end, you DID NOT actually have a med error. But you did learn a valuable lesson about trusting the technology - and also uncovered a potentially serious problem with technology in your organization. My take? It was a win-win situation.

But if the patient is not getting adequate relief, you really need to work with the doc to fix that.

[RN403, BSN, RN]

It is okay to feel upset after any mistake is made. However, it is important to remember that we are humans and we make mistakes. If there was no order to D/C in the physical chart or in the electronic record then you had no way to know that medication was discontinued. Yes, a mistake happened, but, you all can learn from it and prevent it from happening in the future.

The minute an order is received (ideally) it should be placed in the physical chart and relayed to the electronic record.

Best wishes.

[Bellarn80]

Yes your right and I was told that's why we do the 24 hour check each night on the 11-7 shift. I did learn a valuable lesson and when I brought the situation up to supervisor I was told that once a medication was DC'd it would no longer show up in EMAR and that I must have "thought" I saw it when in fact I had. As I was leaving my NPE took the time to dig deeper by looking at EMAR during my assignment and then call IT to see how this could happen because it's never happened before. I felt relieved that IT stated yes there seemed to be a glitch in system and they were going to figure out how to fix it. Ideally when Supervisor DC the order per the MD she should have put it in the file. She printed the DC'd order but didn't put it in the chart until 7am. I assume the MD or RN should have written the order in the chart as well. Everyone especially myself realized that even though EMAR is real time, mistakes can happen. I plan on always passing along in report and documenting that I reported it to oncoming nurse from now on in case a situation like this ever happens again.

I still have a lot to learn but I'm praying not to make mistakes. I triple check overtime I pop a med.

Thank you for your input

[Bellarn80]

Yes your right, when I heard this has never happened before I was nervous but relieved that it came to light so they can fix it.

I believe that's why they d/c the prn order and now made it a scheduled p6 hrs.

Thank you for your input, I really appreciate it!

Best Wishes,