My First Medication Error

[miss_sabrina45`]

Hey everyone, I'm new to this site and I just wanted to share with you my first medication error that I made tonight.

Tonight, I had seven patients and had begun working on the 2000 medications. I became distracted with patient number 1 and once I got out of that patients room, I began working on the medications for patient number 2. For some reason I mixed the two patients up and I gave patient number 1's heparin to patient number 2. 5000units subcut. I feel absolutely horrible!!! The patient was informed, as was the doctor and charge nurse. I was told that its going to be okay, and all that will have to be done is some PTT bloodwork. I'm feeling so incompetent and useless. I cried for a whole hour at work tonight before I could face my co-workers. Some comforting words would be appreciated...

Thank you for letting me vent.

[newnurse1210]

Sabrina,

I know how you feel. I am a new nurse (graduated May 2010) and I just made my first med error. I feel awful too, but keep telling myself that it'll pass and hopefully not happen again.

Since I've been in a dull mood since it has happenend I thought I'd share it with everyone. I hope everyone learns from my mistake, i sure have.

So yesterday I worked a 12 hour shift, it was my third day off of orientation on a Medical Floor. It was just about the end of my shift when the CNA called to inform me that my pt (new admit in ARF-- that had been gone for a few hours at tests) had just gotten his food tray and had a blood sugar of 40 (asymptomatic) and a blood pressure of 71/45. I called the other RN I was working with (we work in teams) and she talked to the Dr who ordered a fluid bolus and an amp of Dextrose 50% IVP. I removed the D50 from the accu-dose machine and took it into the room to verify it with the MAR. The MAR said for 1/2 amp give 3 ml over at least 1 min. I was in a hurry and misread this thinking the 1/2 amp over 3 minutes so I gave the full AMP over 6 minutes:(. I think I misread this because the only other time I gave it was when I went on an ambulance run as a student and the paramedic had me push D50 instructing me to push it in as fast as I could. The sad thing is that I wouldn't even have realized that I had done something wrong because the other RN came and asked if I gave the D50 already and she was surprised to find out that I was already done with it considering its supposed to take 18 minutes! When I found out, I had a hard time believing her considering my experience on the ambulance run, and then I looked back at the MAR and my heart sank.

After I gave the medicine the pt, telemetry called saying that my pt was having some ST depression. The MD had me do an EKG which was fine and the pt didn't complain of any chest pain. After this I filled out an incident report. The nurses I worked with at first didn't think I should even fill one out (admitted to having given this faster than they should also), but then they thought I should in case something would be made of this. I feel so bad, I try so hard to try to be safe and double check things and then I do somethign like this. I hope nothign happened to the pt after I left. I haven't heard anything from my boss yet, but I wonder what is goign to be made of this...

[CrunchRN, ADN, RN]

I don't get it. I guess because I am not a hospital nurse I am very rusty on that stuff. I would have thought I was supposed to give 6ml over 2 minutes if it said for 1/2 amp give 3 ml over 1 minute. And I have been a nurse over 17 years so don't feel too bad!

The important thing is too just learn from it.

[newnurse1210]

The vial (an Amp) of Dextrose 50% is 50 ml. I was supposed to give it over 18 minutes IVP instead of 6 minutes:(

[CrunchRN, ADN, RN]

I get it now. Didn't realize it was 50 ml. Still, nobody was harmed. You will never forget proper admisitration of D50 so let it go. We are all human.

[radgey]

hi i am a new nurse and i have made 6 medication errors in less then two month, i am so mad at myself being new isn't an excuse so i worry and don't sleep. the errors that i made 4 of the mistakes i made were missed doses of narcotics like norco. and one i accidently gave two instead of one. I am so mad at myself its not funny. I try so hard. I work in a nursing home and pass meds to 22 residents am i the only one who has ever made so many med errors in such a short period. i am so worried what my employer thinks about me, i try so hard and still miss the dang dose. i am on a med error role and i think i have the record beat state wide. has anybody else ever made many med errors in a short time.

[tokmom, BSN, RN]

This where bedside scanning would be invaluable. Don't beat yourself up over this. As the others have said, if you learn and change your practice so it doesn't happen again then you will be fine. It's those that cover them up or say they have never made a med error are the ones to be afraid of!

[Frankie Slade]

It's okay, nobody died. You did the right thing by being honest and reporting it as soon as possible. We have all made med errors. Nursing is a tough gig, especially when they understaff the floor, which can make any good nurse prone to error. We are humans, forgive yourself. You did your very best, and that's what counts. If hospitals really cared about the well being of their patients then they would staff accordingly. Hospitals only care about the profits. It is the nurses job to protect their patients from these greedy hospital administrators. Good Luck, and God Bless.

[radgey]

thankyou the bottom line is i have thought about how can prevent this from happening again. I quit that job before they fired me just because i had a hunch,gut feeling instinct. My instincts are usually accurate. Well update: my instinct was right on but i will not go into detail how i know this. One thing i have learned from this is your right Frankie Trust Noone. Sad to say but watch out for those wolves in sheeps clothing. Pay close attention to body language, eye contact and read between the lines, don't say anything that can and most likely will be used against you at some point and time. Be strong, self confident even when you don't feel that way sad to say but i guess that is the only way to survive nursing. Thanks for your support

[radgey]

Fake it until you make it trust yourself, trust God learn from your mistakes and move on. Having a good mentor helps:)

[PinkNBlue, BSN, RN]

Big big hugs to you. I am a new nurse as well and medications scare the bejeesus out of me.