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My first med error... Yikes!

Nurses   (5,810 Views 14 Comments)
by RiverNurse RiverNurse (Member) Member

RiverNurse specializes in Certified Wound Care Nurse.

10,092 Profile Views; 170 Posts

Hi all,

So, I've been a nurse for 3.5 yrs now. I guess it was bound to happen??? How could I have been so stupid?

Synopsis: Working midnight til 8 am... No nursing assistants on the floor so we are doing total care, charting the initial assessments for LPNs and so, are obviously short staffed.

I hang an IVPB of Fortaz right before shift change. It's infusing, but it doesn't look right... it just doesn't register with me... However, it is the right patient, right time, right med and right dose. So, I check on it again, it's infusing - so I give report, let the day shift nurse know it's infusing and I go home.

Two days later my manager wants to talk to me. She says there has been a med error. The primary fluids were hanging above the IVPB. So, I get written up.

GEESH! How could I have been so stupid? :banghead::banghead::banghead::banghead:

Once I collect my thoughts and stop internally freaking out about making this type of mistake after having been on the floor for so long, I asked her what the final outcome/resolution was. She said, "I don't know, yet. I have to finish my investigation." I paused, then said, "Well, I was talking about the patient. Is he okay? What type of negative impact did this have on him? How adversely did this affect him?" She said, "I don't know. He's been discharged for two days."

Tomorrow is another day... ;-)

Rivernurse

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chicookie has 8 years experience as a BSN, RN and specializes in Peds Hem, Onc, Med/Surg.

985 Posts; 10,677 Profile Views

That nurse manger sounded like my nursing school instructor, any and all questions were responded with an "I don't know." :D On the bright side it sounds like the patient was fine. :)

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RNlovesherPharmD has 3 years experience and specializes in Labor and Delivery.

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I'm glad it turned out ok for your patient. You didn't give the wrong thing, I think if both fluids are on the same level...they just both infuse quickly if not on pump, or if on pump just the main bag infuses. Your boss should be more constructive and I feel a write up was a bit extreme.

If it makes you feel any better, I've been known to hang a PB without realizing I hadn't opened the stop---until over an hour later and the PB was still full hahaha

Such is life. I wouldn't beat myself up over this :)

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21 Posts; 882 Profile Views

My goodness those responses by the NM would just irritate me...

We all are going to make mistakes, however, patient was not harmed and you learned something from this. I know someone who I work with that hung vanco to the lowest port in the primary tubing without programming it to the pump, so as you can imagine the vanco infused in about 2 minutes!

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psu_213 has 6 years experience as a BSN, RN and specializes in Emergency, Telemetry, Transplant.

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First, you said it happened right at shift change. The nurse following you should have just hung them correctly, let the abx. infuse, tell you about it the next time around, and thats thats.

Our incidient reports had a section for "Probably cause of the error." Some choices include "staff inexperienced," "order illegible," "transcription error," etc. One of the choices was "insufficient staffing." If there was even a chance that staffing was not sufficient, I would choose it (which would be most of the time).

Anyway, it's a relatively simple error, no harm to the pt...not a big deal--learn from it and move on. As for your NM, she needs to chill out. I'm sure she has bigger things to worry about.

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NightOwl0624 has 6 years experience.

536 Posts; 9,729 Profile Views

My "big" med error (same sort of thing) absolutely was due to short staffing - on a holiday - with two very sick and time intensive patients and a new admission. I didn't take the time to think through what I was doing because I was already running out the door to the next patient.

I wish management would take that into consideration, but they don't seem to care and it does sound like a lame excuse - unless you've lived it!

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Forever Sunshine has 7 years experience as a ASN, RN and specializes in LTC.

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First, you said it happened right at shift change. The nurse following you should have just hung them correctly, let the abx. infuse, tell you about it the next time around, and thats thats.

Our incidient reports had a section for "Probably cause of the error." Some choices include "staff inexperienced," "order illegible," "transcription error," etc. One of the choices was "insufficient staffing." If there was even a chance that staffing was not sufficient, I would choose it (which would be most of the time).

Anyway, it's a relatively simple error, no harm to the pt...not a big deal--learn from it and move on. As for your NM, she needs to chill out. I'm sure she has bigger things to worry about.

I think that would be the box I pick for most incidents in my facility.

If it wasn't on the form.. I'd make one on the side lol.

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iNurseUK has 20 years experience as a RN and specializes in Plastics. General Surgery. ITU. Oncology.

348 Posts; 6,316 Profile Views

We ain't human if we don't make the odd error. God knows I have but never anything that caused harm.

My unit is currently struggling with these new infusion pumps wished on us by the powers that be. They are bloody awful. Twice as complicated than our old pumps and prone to alarming for no reason any of us can discern. Yes they have all the bells and whistles features but it speaks volumes that after only 3 weeks on the ward three of them are in for repair.

Progress. Don't you just LOVE it? :)

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135 Posts; 3,165 Profile Views

My goodness those responses by the NM would just irritate me...

We all are going to make mistakes, however, patient was not harmed and you learned something from this. I know someone who I work with that hung vanco to the lowest port in the primary tubing without programming it to the pump, so as you can imagine the vanco infused in about 2 minutes!

I had a nurse do that TO ME with doxy. EXACT scenario. I tried to tell her it was infusing too fast. I even had her come back in and look at. She swore it was fine. 5 minutes later when it was finished, I clamped it and called her in to tell her it was done. She pretty much turned white, got all stuttery and said that shouldn't have happened, and blamed it on the pump. Funny thing though, the NS ran just fine through the pump after that. Then she gave me an attitude for the rest of her shift. Nice....

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I am a new nursing student that recently had finished my 3 clinical classes. I never had made a mistake involving medication but caught too mistakes on the medication list that i had for the pt. I first notified my clinical instructor and she told me that i did the right thing about notifying her. Once the situation was corrected, I preceded to triple check the medication i gave with the clincial nursing instructor. The instructor stood nearby while i gave insulin and morphine to the pt. I know mistakes happen and though it was not intentional, the only recommedation i have for you is to move foward. Im not totally sure how they would handle it, but count your blessings if the pt. is not harmed. If their was severe harm done Im sure you would probably have more than a write up. Just count this mistake as warning to keep your eyes focused. Do not feel that you have to rush and if you don't know if your doing something right, just ask! With that in mind, just keep your head held high and things may come together. My religious belief is that god wont give you something you can't handle, and everthing happens for a reason.

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3dayRN specializes in stepdown RN.

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It doesn't seem like a "med" error to me. The 5 rights were correct. The oncoming nurse should have just corrected it. This is something that DID NOT need to be reported to the supervisor. Seems like this nurse and supervisor has too much time on their hands. I could see pointing out your error so it would not happen again but should not be a disciplinary action against you.

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LTCangel has 23 years experience as a ADN, BSN, LPN and specializes in LTC, Skilled Rehab, Med/Surg Float Pool, Ortho.

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Med errors are supposed to be used as an educational redirection, unless of course a sentinal event occured. Even then, it is used to reeducate the entire staff and change policies. We are taught in Nursing School and encouraged to self report med errors, but when NMs use this as a reason to discipline it causes nurses to try to cover up mistakes. I can see disciplinary action if a certain nurse was consistently making med errors or was obviously negligent and sloppy but we are human and mistakes to happen. You try to fix the error, call the doctor, monitor the pt, and document the incident. I just don't understand Administration nowadays, it seems as though Nurses are burned at the stake for everything! Not to mention coworkers who try to get each other into trouble. In my 15 yrs I have made a handful of med errors that thankfully did not lead to any harm to the pts, but my NMs used it as an opportunity to re educate me in the 5 rights and to be more careful. Once a co worker made a more serious error and our NM had her to do an inservice for the unit to not re educate herself but to keep the rest of us from making the same mistake. Always be as careful and vigilant as possible but just know that you are human and I feel this NM juat wants to "make herself look good", so to speak. Just sayin'... Lisa

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