My first medication error, I'm freaking out

Posted
by FNPStudentLife FNPStudentLife, BSN, RN Member Nurse

Specializes in ER nurse, FNP student. Has 5 years experience.

During my 3 years as an RN, this is the first time that I've made a medication error. I was supposed to give medication for the heart rhythm, but instead, I gave an anxiolytic/sedative. What happened was the medication was not available in the Pyxis, so I went to get it from the pharmacy. The printed label on the packaging had the right name of the patient, the right medication name, and the right dosage. However, the inside of the packaging had a pre-filled syringe with the patients name, but a different medication name. The two medication names looked very similar (similar in length, first 2 letters, and last 2 letters). I scanned the patients wrist band and the PACKAGING (which I shouldn't have done...). And I pushed the medication that was inside. I was pushing the medication slowly constantly watching the heart rhythm and heart rate. Halfway through as I was looking at the syringe, I realized the syringe has the wrong med name and stopped. The physician was notified immediately and the incident report was filed. Thankfully, no harm was done to the patient, and s/he just took a 30 minute nap. There was a lot of risk involved though, the physician said its good I stopped when I did because if I pushed all of the medication/or if I had pushed too fast, it's possible that the patient would have to be intubated considering their medical condition and age.

Few days after this happened, I received a notification that there will be an analysis review that I'll have to attend. I never attended anything like this. Is this common for medication errors? Also, is this something that will be reported to the board? Do I have to mention this when renewing my license? Did anyone had a similar experience?

JKL33

6,382 Posts

It sounds like a meeting for the purposes of examining all possible factors that contributed to the situation for the purpose of determining whether processes need to change or whether a policy was unclear or similar needs for change. Your role at the meeting is to report what you know about it and/or clarify any of your own actions/rationales if necessary.

I have only attended in situations where my personal actions/involvement were not what was being questioned.

It's anyone's guess as to the specific manner and tone with which they will undertake this. It seems like something that is variable based on the culture of the facility and how the involved individuals view this (similar to how some places wrongly treat incident reports as punitive "write ups" instead of a tool to track errors or near misses and a valuable safety/improvement tool). Hope for the best, though!

My strong advice is that you do not visibly freak out, and that you do not attend with your tail between your legs but rather as someone there in the interest of helping figure out how this can be avoided in the future beyond just the idea that you could have checked both labels. This two-label system (apparently without the use of duplicate labels/two copies of the same label) is begging for this very error (which originated in pharmacy). Another possible pitfall is that the label on the bag was apparently able to be scanned - - that shouldn't be the case (especially being that it was not an exact duplicate of what was affixed to the syringe); it should be for informational purposes only. Only the label directly affixed to the syringe should've been able to be scanned. In short, there is more than one alternative process that could have prevented this. You are right that since there were two labels, your better move would have been to examine both of them equally, and scan the one affixed to the med. I would admit that but not belabor it or in any way comport myself in a manner of self-deprecation during the meeting.

If the committee were to satisfy themselves with, "Well, ally1991 shouldn't have done it that way..." then another error exactly like this one is going to occur.

I would go in with a positive attitude and expect the best and participate responsibly and with confidence along the lines described above.

It isn't a tribunal; it'll be okay. ??

Horseshoe

Horseshoe, BSN, RN

5,879 Posts

You have learned a valuable lesson. Hopefully you don't bear the brunt of the blame here, as clearly there was an error made by someone in pharmacy. The important thing is the patient was not harmed.

Good luck, and I hope you can report back and let us know how it went.

myoglobin

myoglobin, ASN, BSN, MSN

Specializes in ICU, trauma, neuro. Has 14 years experience. 1,453 Posts

It goes without saying that if this is a union facility that you should notify your representative (just another reason why unions are important beyond pay and benefits). This is mostly as "systems error" in that the scanned portion doesn't correlate (necessarily) with the medicine. If they address the system issue in line with the To Err is Human Report, then good for them. If they instead blame you, then it is ironic that you will be in trouble for reporting something that would have gone unnoticed, but for your timely interventions. They will be creating a disincentive to future nurses. Indeed, one wonders how many times the Pyxis has been loaded with the wrong medication and it was perhaps given without being noted.

K+MgSO4, BSN

Specializes in Surgical, quality,management. Has 12 years experience. 1,753 Posts

Breath!

As a former quality consultant this is something that I was involved in for incident investigations. What your hospital is doing is looking to see where all the holes lined up like swiss cheese to cause this incident.

As the doctor said to you that day it is a good thing you stopped at the point you did so the pt did not end up tubed.

All that should be asked of you is what you did that day. If you want to do some research into risk and quality search terms such as "the 5 whys" "safety engineering " "human factors " are a good place to start.

WhilevI do not work in the US this is not the stuff the nursing boards are interested in. Jump on the relevant state board website and see why people are removed from nursing, it is not a medication administration error.

subee, MSN, CRNA

Specializes in CRNA, Finally retired. Has 50 years experience. 4,279 Posts

Boy, do I remember that horrible feeling when making a med error and it was decades ago. Keep it in your mind that 1. No harm was done to the patient and 2. You will probably not ever make a medication error again. This kind of stuff humbles us and tincture of time will heal the feeling of incompetence. When it happened to me, I eventually realized how lucky I was that it wasn't harmful and that I was a stupid human being and will be uber alert in the future.

JBMmom, MSN, NP

Specializes in New Critical care NP, Critical care, Med-surg, LTC. Has 10 years experience. 4 Articles; 2,284 Posts

Your first med error after three years shows that you are a nurse that is conscientious in your practice. It's called an error for a reason, you didn't do it on purpose, and fortunately, no harm came to the patient. You've learned the lesson, just present it as such if you're asked about it. You're accepting blame for the part you played and that's appropriate, you will be more vigilant in the future. And maybe your pharmacy needs to add a layer of checking to ensure that the outside label and medication label match. Good luck! Don't worry too much, you will be fine.

Guest219794

Guest219794

2,453 Posts

First, and most important, no harm done.

Almost equally important is your attitude, which is great. Many people would be defensive, and you are not. With the system errors that occurred, many nurses would have made the same mistake. I am guessing that many here have scanned the outer packaging of a medication.

If you work in a good facility, this error you caught will make the facility safer.

I think med errors are far more common than anybody knows. There is just no way to measure them. We only know the ones we catch. Look at the mislabeling that caused this error- how many other packages were mislabeled and given before you noticed? There is no reason to assume this is the first time that this system error caused an error, this is just the first time it was caught.

There are nurses who will say "my first error in 10 years of nursing"

Let's say that nurse is on med surg, has an average of 5 PTs a shift, each getting an average of 10 meds per shift. I don't work med surg or ltc, but I am thinking that that is pretty conservative, and that there are a whole lot of nurses administering a whole lot more medicine than that.

This nurse works 150 shifts a year. That is 75,000 medication administrations in that 10 year period. And after 10 years, he catches an error and assumes it is his first.

Thanks for sharing your experience. The more we share our mistakes, the fewer we make. Any chance you could share the specifics on the two meds?

FNPStudentLife, BSN, RN

Specializes in ER nurse, FNP student. Has 5 years experience. 1 Article; 36 Posts

13 hours ago, hherrn said:

First, and most important, no harm done.

Almost equally important is your attitude, which is great. Many people would be defensive, and you are not. With the system errors that occurred, many nurses would have made the same mistake. I am guessing that many here have scanned the outer packaging of a medication.

If you work in a good facility, this error you caught will make the facility safer.

I think med errors are far more common than anybody knows. There is just no way to measure them. We only know the ones we catch. Look at the mislabeling that caused this error- how many other packages were mislabeled and given before you noticed? There is no reason to assume this is the first time that this system error caused an error, this is just the first time it was caught.

There are nurses who will say "my first error in 10 years of nursing"

Let's say that nurse is on med surg, has an average of 5 PTs a shift, each getting an average of 10 meds per shift. I don't work med surg or ltc, but I am thinking that that is pretty conservative, and that there are a whole lot of nurses administering a whole lot more medicine than that.

This nurse works 150 shifts a year. That is 75,000 medication administrations in that 10 year period. And after 10 years, he catches an error and assumes it is his first.

Thanks for sharing your experience. The more we share our mistakes, the fewer we make. Any chance you could share the specifics on the two meds?

The scheduled medication was Diltiazem 10mg. I administered Diazepam halfway (so 5mg).

Guest219794

Guest219794

2,453 Posts

Diazapem in a pharmacy filled syringe? Odd. Thanks for sharing.

I had an ER PT come in from home after getting the wrong bubble pack from his pharmacy. He generally eats a handful of meds in the morning, but he ate the wrong handful.

Meriwhen, ASN, BSN, MSN, RN

Specializes in Psych ICU, addictions. 4 Articles; 7,907 Posts

The fact that there was a different medication in the packaging is alarming. Yes, ideally you should have caught it...but you know what? The wrong syringe shouldn't have been in the right box in the first place. So IMO, pharmacy is just as culpable as you are.

As far as med errors go...the patient didn't die, no harm was done. You notified the provider as soon as you caught it and took care of the patient. So don't beat yourself up too hard.

Reread JKL33's advice about how to handle yourself at the review as I think it's great.

And don't stress...you're not going to have to mention this on your license renewal or on job applications. Though it can make for a good story to use for one of those "tell me about how you handled..." interview questions.

Best of luck.

myoglobin

myoglobin, ASN, BSN, MSN

Specializes in ICU, trauma, neuro. Has 14 years experience. 1,453 Posts

I think one of the main take away lessons is that pharmacy should also use scanning when dispensing medications and as importantly the bar code used should be integrated from the smallest packaging possible (or the syringe in the case of a syringe). This would decrease the likelihood of this error occurring.