huh!!, hi everyone, i'm a new lpn grad working in the nrsghome for about 3months, i got my first write up yesterday!! you see i work at night, and usually the night nurse audits the md order book to the mar to verify the new med orders, so i audited and made sure that the orders in the md order book and the mar matched, but i missed 1 order and the patient did not get an additional 3mg of coumadin for 4 days!, until another night nurse caught it!! so the supervisior basically gave me a good yelling at plus a sympathetic pat on the back! she told me that i was doing well but this med error is unacceptable and so i was written up!!. the thing is i was building up my confidence and much of my anxiety as a new nurse was going away, now that this happened i feel that anxiety coming back!! i even know where i went wrong, i kinda rushed through the auditing that night because the shift was ending and i was working a double shift and had to get to the next unit!! i realize that i make mistakes when i rush and things get hectic. the supervisior had spoke to me before about other little things i forgot to do!! all in all its a learning lesson and the other nurses tell me its one big learning process, but its so scary, when things go wrong, no one cares about how inexperienced you are!! i just needed to vent!! my i's and t's will definitely be dotted and crossed after this!! thanks for listening!!
Specializes in Pain Management, RN experience was in ER.
Don't beat yourself up :) You sound like you're coping much better than some of the new grads I've worked with in the hospital. You know, the ones that don't give their 2100 meds, so they tell the nurse coming in at 2300 that she needs to do them becuase she's not staying until 0100 again to finish charting... so they werent given until midnight? I'm glad you're TRYING. That's all you can do. You can bet your britches that the more senior nurse's didnt start out being perfect... and they still aren't there :)
Last time I checked there was only one person in history reported to be perfect, and even he got nailed for other peoples mistakes. Double shifts are famous for increasing the number of med errors. Do you usually do a good job? Are you comfortable with your responsibilities most of the time? You are going to make a med error, or miss a problem in your assessment, or make an error in judgement once in a while.-all of us do. The institution has to document the error to track chronic offenders who aren't safe in thier position. Be concerned about the error but realize it won't be your last. The good that you do most likely far outweighs an occasional error. Learning we are not perfect and still accepting the responsibilities inherent to our profession one of the hardest lesons to learn. Many of us struggle with us our whole careers.
If it helps you in any way, I'll fess up too. I've made the same coumadin mistake (way back with paper mars). The patient went a solid week until the med nurse picked it up, GOD she was excellent. I was embarrassed, regretful, self hating, angry, ashamed, fearful of a repeat, questioning my ability to screw up for years to come and live with it... I still FEEL all these emotions, they're just in check now.
I've made it 13 years later, still make med errors, no matter how hard I work dilligetly not to but I won't make it twice. I share my mistakes with everyone, so they won't do it as well, If my patient knows, I make sure it's clear I've fessed up, tell them the doc is aware and what they'll do differently and have even asked my patient if they would feel more comfortable with another RN.
Not saying I have med errors weekly, but over 13 years, there WILL be more than that first one. Learning what to do from the RN side is only a part of the post error to do list, learning how to handle making the error on the human side has always been the hardest.
I promise you that as long as you CARE, follow the policy, ask questions and look up unknown meds, your errors will be few and your patients safe.
It's a tough lesson to swallow. After you have gotten past it, share it with a new nurse who has just had their first med error, or a doozy of one. Helping each other through these things, heals and teaches.
You should not have been yelled at, there is no excuse for that. We are all human and we all make mistakes. I wish facilities and managers would look for reasons for errors instead of destroying the confidence of their overworked staff trying to do the best they can.
Hang in there. You sound like a very caring nurse. Learn from what happened and remember it happens to everyone.
Thanks Dee, for recognizing that the original poster's situation represents a systems failure. Her LTC facility appears to have no system in place to catch human errors that are bound to happen. If she were instead working at an acute care facility, risk & quality would be looking at the system that allowed for 4 days of incorrect doses of a crutial medication. Thankfully, acute care is moving away from the "you're a bad nurse" response and recognizing the bigger picture.
To the original poster, you should ask your supervisor why there is no system in place to catch such med errors, and you could offer to work with her to change the current system that allows for such errors. If your LTC facility is part of a chain, there may be corporate quality assurance and risk management help available in re-mapping your medication order system.
Good luck with this,
HollyVK, RN, BSN, JD
OK, I think this is bullcrap!! I would call this a "system" error of which you were a part. There should be a double check on MD orders, with 2 nurses checking and signing off on the orders. (Or a HUC and a nurse). But there should be 2 sets of eyes doing it. This is far too important to leave to 1 nurse on the night shift who is rushed to verify ALL the orders for the day... you've got to be kidding me??!! And then your manager had the BALLS to yell at you?? She had better turn her yelling back at herself and look at WHY the error happened to begin with. This is why a lot of med errors are never reported, it is because nurses are blamed and shamed and the underlying issues aren't addressed. Personally as a new grad nurse of only 3 months, I would have been very nervous to be the sole person responsible... I don't know what to tell you about how to address this but perhaps at some point you could ask her if they ever had 2 people sign off the MARS. How does it work at the end of the month? Does just one person verify the new MARS, or are they double checked? All the LTC facilities I worked at, always double checked all med orders...
Most of the time I believe the bosses are too nitpicky for their own good but this is a pretty noticeable medication error. Warranted a good butt chewing but I'll bet you'll watch for things like that in the future.
Don't feel bad, though, we have all had our share of butt chewing.
You said you were working a double shift as a new LPN and had to rush over to the next unit. As a new LPN, I would be careful about working doubles. The words double shift, rushing and new nurse are to be considered in missing this med dose. Don't be too hard on yourself, you are still learning. I say do not take on more than you can handle. It does take time to know your limits, take care of yourself. You are already a great nurse for caring so much!
Specializes in Community Health, Med-Surg, Home Health.
If the supervisor patted you on the back, but also corrected you, it sounds to me that she is supporting you; but felt the need to write it up, because Coumadin is a drug that really needs to be monitored. I would go to her, sincerely apologize, and learn from the mistake. Most of us hate to be written up, it is a blow to the ego. But, we learn from them. Actually, that is what the disciplinary process is SUPPOSED to be, but there are some people that really get carried away for no good reason. I am not saying that you deserved to be written up, or that I support it, mind you. Good luck!
Specializes in Med/surg,Tele,PACU,ER,ICU,LTAC,HH,Neuro.
Who ever noted the order after the doctor ordered it is the person legal responsible. As an auditor all you do on nights is try to find the ERRORS. OPPS you missed one. Ain't your fault legally and you should only be told to try to be more careful. DON"T BE THEIR freaking scapegoat cause it wont hold up in any court. QA has a job to do and it is not to place blame on anyone but to get to the root of the med error.
I am a new nurse too, and I know how that feels, but let me tell you, if you ask some of your coworkers how it went for them when they were new I guarantee you will hear some whoppers, if they are willing to share of course. Every time I make a mistake I really go all out and get upset, but my coworkers were willing to share some of their experiences and it made me feel that I still belong there, and that I am good at what I do. :typing
who ever noted the order after the doctor ordered it is the person legal responsible. as an auditor all you do on nights is try to find the errors. opps you missed one. ain't your fault legally and you should only be told to try to be more careful. don"t be their freaking scapegoat cause it wont hold up in any court. qa has a job to do and it is not to place blame on anyone but to get to the root of the med error.
well the person who recieved the order on the day shift should have noted and written the extra 3mg of coumadin on the mar, but at this facility the night nurse is expected to audit and initial all new orders, what you're saying is true because the morning nurse is the one recieving the orders, so the night nurse isn't there to know what orders were and weren't and another thing is that all new orders are supposed to be flagged in the md order book, so if someone deflags an order or forgets to flag it, the night nurse probably would still get blamed for not catching the orders, that thought passed through my mind when the supervisor was speaking to me but i didnt want to seem like if i was making excuses!! thanks anyway!
shannonFNP, BSN, MSN, RN
263 Posts
Don't beat yourself up :) You sound like you're coping much better than some of the new grads I've worked with in the hospital. You know, the ones that don't give their 2100 meds, so they tell the nurse coming in at 2300 that she needs to do them becuase she's not staying until 0100 again to finish charting... so they werent given until midnight? I'm glad you're TRYING. That's all you can do. You can bet your britches that the more senior nurse's didnt start out being perfect... and they still aren't there :)