New Nurse 4 Med errors in 6 months

[lpncharlie]

Hello I Graduated In December 2010 and maintained high grades throughout the program. I passed my state board exam on my first attempt in February. A friend recommended me to a local nursing home where they agreed to hire me as an 8hr a week employee. Orientation was about 4 weeks where I mostly watched the regular staff scurry around and complete their duties. The facility has 4 units with 32 patients each. During days and evenings they have 2 nurses that care for 32 residents each and 3 nurses that care for 21/22 residents each. During orientation I was all over the facility and oriented different shifts with different nurses on different units without really much hands on time because the regular nurse on the floor needed to keep things going in order to do her job. I had the opportunity to pass meds a few times during orientation.

Orientation ended and I became a floating charge nurse. I work whatever unit or shift they need. As a new nurse without knowing the residents very well it is very difficult to do the med pass. On a couple of units, many residents require crushed medications and or thickened supplements and are difficult to feed. The regular nurse knows the residents well and has the ability to streamline some of their duties, for example, they put supplements on the resident's tables and the regular aids thicken them and feed the supplement with the meal. By the time I get to these rooms scattered throughout the unit, the meal is already over. It is difficult to know each residents needs because I do not work any unit or shift with frequency. Obviously nurses do not "follow the book" and do what they need to do in order to get their job done.

The facility utilizes paper Kardex's for medications and treatments. From my little experience it becomes evident that this method is problematic and prone to errors. Every medication is listed and during a med pass the nurse has to view each line identify which meds are to be given now, administer it, and sign for it in the appropriate square. When dealing with unfamiliar residents this takes much longer than it does if you know them. I can't help but notice all the unsigned squares. It becomes evident that the regular nurses that "forget to sign" simply fill in the squares the next day. In my opinion the floating nurse does not have that opportunity and is under more scrutiny.

After six months of employment, I have made 4 reported med errors. The first was that I recognized that a resident drank little of the juice I added her potassium chloride to. I poured it into a 30cc cup and decided to try to give it undiluted to the resident with the hopes of getting them to drink it all. I administered the other medications and some of the KCL was found 20 minutes later by the supervisor on their table. Error 2. I administer a narcotic scheduled at 8am. At 10:30 I administer another scheduled dose in error. It was not supposed to be started until the next day. I read the wrong square. Error 3. I enter a room and realize that the door resident is in the bathroom so I pour and administer the window resident's medication. With my cart facing so I can see into the room, I pour the meds for the resident in the bathroom. She has not left the bathroom and another resident comes in the hallway and asks for her medication. Without moving the cart, I pour her meds and turn to her and administer them. I then proceed to the bathroom door and knock. Enter the bathroom and administer the meds. I administered the wrong meds to the wrong resident. The door resident left the bathroom and the window resident went in. I noticed this right after I made the error and notified the supervisor of my error. No ill effects noted but in my opinion this was a terrible med error. I vow to myself to always know my patient and identify them prior to ever giving meds again. Error 4. Resident was to have a tooth extraction and was to receive an antibiotic 1 hr prior to the in house procedure. When told to give I looked for it, found it and administered one antibiotic and signed for it. The order was written for 2gms and I administered 500mg. These errors happened over a 5-month period. I am at fault for all the aforementioned errors. They should never have happened. Even though I never had the experience of giving multiple antibiotics at one time, I administered an incorrect dose. Obviously if I ever see a punch card with 4 antibiotics in it and a procedure is scheduled or a single dose of antibiotic is scheduled, I will check the order very carefully as I should check all orders. In school most people would envy a grade of 99. In nursing if you administer 5000 medications but only 4999 are correct, that is not good enough.

The director now wants me to work for 2 weeks with the day nurse on one unit. She does not have a regular position to offer me. So working on one unit will not be an option in the near future. I have however become somewhat familiar with a good portion of the residents. The director asked me what I needed to learn. I think what will be best for me is for this nurse to work at my level of not intimately knowing the residents and show me how to possibly get both med pass's done along with treatment notes, admissions, and all other duties. The unit is broken down so half the residents are scheduled to have meds at 8:30am and the other half at 9:30. I find that by starting at the first room and working my way around the unit, it is impossible to get this done in a timely manner especially when the nurse has to do finger sticks and coverage for diabetics, check B/P's & Apical for parameter medications, and get meds to people before PT or going out and identify each medication to be given going through the Kardex like a nurse that is not familiar with the resident would have to do?

Should I be able to walk into a unit that I seldom work and proficiently get the job done? How can a nurse in my situation follow procedure and timely administer medications to 32 residents many that are crush with parameters while doing finger sticks? What happens when I get to resident 32 and realize that they are diabetic and need insulin before breakfast and it is now lunchtime? Supposedly in a couple of weeks they are changing to a computerized system that I would think would help isolate the meds to be given eliminating all the time of looking through all the orders that are not relevant at any particular moment.

Am I a loose cannon a bad nurse? I always thought I was meticulous. My errors indicate otherwise.

All input and responses are appreciated.

Thank you

[IowaLPN]

This is just an opinion.... I feel that you should try to find a "regular" job and not be a float nurse. When we have new grads that float in my facility I always feel badly for them know that they are going to make mistakes and probably won't be there for very long. Floating and taking care of 30+ residents is an unfair and impossible task I believe. I know it's a tough job market but I think you should look for a "non float" job.

[bulletproofbarb]

yes I agree with that. You need, as a graduate to be somewhere stable and float is not stable. I did not even consider working float or casual until I was 5 years out! I was far too scared to throw myself in the deep end.

Start looking for a permanent job and in the mean time, all I can advise is to be really careful, double check and prioritise. I am not sure if you get a basic handover, but if you do, single out the priority patients, like diabetics, do those first and then do the others.

[SuesquatchRN, BSN, RN]

I agree with IowaLPN. These are almost inevitable given your circumstances. Look for a non-float spot and hang in there. When I was floating as an LPN in LTC I had a med error, always omission, probably once a week. It's tough.

[merlee]

Your errors indicate only that this is an overwhelming situation. I guarantee that all of the other nurses are making similar errors but can manage to cover for them.

As for the fingersticks and insulin, it would help to have a seperate listing of those patients, and get them done first.

You are being given an opportunity to stay on and beef up your skills. They see you as a valuable person.

Best wishes!

[interleukin]

Rule one...all new nurses make errors.

Rule two...remember rule one.

If your patient load is overwhelming forcing you to rush in order to complete tasks, carefully consider your employment.

If you are rushing...going against your better instincts to be methodical and measured...stop it. Never exceed the speed of safety no matter how late you are.

You'll get used to things. But don't destroy your reputation or peace of mind before you get there.

And, yes, floating without a solid core of experience will end in misery.

[Sun_danc3rRN]

Sounds like you are in an overwhelming position for your training, or rather lack of proper orientation. I would look for a job where you are not a float nurse, and certainly not a charge nurse at this point in your career. Med errors happen, and it sounds as if you have learned some valuable lessons from them. In the meanwhile take your time, make sure you get a good report of how people take their meds, crushed, etc. and try not to rush even though you feel the pressure to do so..Keep your chin up. :)

[kcmylorn]

I don't think you should beat your self up with negative self talk. This is a SYSTEM problem. (repeat that several times to yourself) This is called 'Short staffing', dangerous staffing levels 1 nurse for 32 patients and LTC patients to boot. Patients who are cognitively and developemental impaired require a lesser nurse patient ratio to be competently and safely cared for.

I had a 3 month hands on same position as yours part time job in LTC 2 yrs ago after doing exclusively acute care hospital bedside for 30 yrs!! Yes, we nurses from the hospital give out meds at certain designated times of our shifts((8,10,AM- 12,2,4 and 6PM) but not to the volume of patient that LTC does. Whole different animal but still a basic med pass with the 5 R's and rules, regs. During my 3 month orientation in LTC fresh from the hospital(telemetry and stepdown) I too was floated from unit with meds to give for 32 patients and met the same obsticles you did- patient nuiances- crushing, mixing, camoflageing meds etc. I gave one pt's narc to another pt- luckily both patients were on the same narc, same dose, same time. It was more a matter of who was getting charged for whose med. The panic one feels in that situation it unbeliveable. This is the dangers of short staff and 1 nurse for 32 patients IS short staffing!! The true tragedy is- this is the norm in LTC and these staffing patterns are within State Depart of Health guidelines!! 32 patients to 1 nurse is better staff compared to other LTC facilities. I was agency and did some shifts in a LTC where it was 60 patients to 1 nurse. This is a problem that is rampant through out LTC. LTC nurses should be spitting fire but they don't. They have become so used to this nurse/patient abuse that they are complacient about it and "go with the flow" The state staffing regs need to be changed. This is aappauling considering the amout of money it costs for these residents to spent(or their families are spending) to keep them there. If they are private LTC thoses resident's and their families are shellingout big bucks/month AT LEAST $6,000/month. Some families have had to sign the resident's personal home over to the nursing home as payment for room and board. If the resident cannot afford the cost of room and board they look to MEDICAID(welfare) and that resident's home gets signed over to the state or sold off to pay for their stay. This is the way it rolls with a state/county municipality run LTC also. Someone who spends $6,000/month for room and board aka mortgage/rent or hotel bill should be getting a better nurse patient ration than 32 or 60:1 nurse!!

This is not soley your fault- this is the sytem's fault and it is jeapordizing nurses licenses but you would be hard pressed to find a nursing home DON or administrator who cares and tries to fix that problem in their own facility- whether it be backing up and supporting their licensed nurses- aka not letting the aides run a muck(which some do) finding ways to streamline paper work/documentation(most LTC facilities are still handwritten documentation) notations made on the MARs individual patient nuiances for med administration.

These DON's cant just talk about reducing med errors they actually have to do some hands on analysis of the problem, they have to come out of their offices and spend shifts in "hand to hand combat" with these patient'sto get a realistic view of the obstacles the nurses are upagainst and then try to devise a proactive solution: This is the problem, this is what we have, how do we fix it===NURSING PROCESS!!! JMHO Just one more part of the broken American Healthcare system. This would be an easy fix if staffing levels were adequate!!!

[GimiRN]

I used to work as an agency nurse for a LTC facility, and would often have to float between the units. And I can tell you that it took several months to learn every patient and their needs (diabetic, tube feeders, dialysis, etc). And at least that was on the same shift. I couldn't imagine having to jump right in on multiple units AND shifts. That would be overwhelming for anyone.

Unless your director can give you a consistent week on each unit and each shift, so you can get better acquainted with the routine, I agree that you should start looking for work elsewhere.

[33762FL]

I don't think you're a bad nurse. I think anybody could have made those errors if they were a new grad with scanty orientation tossed into LTC as a float. If you didn't have a situation where you had a preceptor telling you that you have to mix liquid K+ with a bunch of orange juice or something because it tastes awful. I'd say get out of LTC if you can, but these days that's not very realistic (with the crummy job market). So do the best you can, and learn from your mistakes.

[nola1202]

Been doing this for 25 years and still made a med error in the early days. Felt like an idiot. I too was bumped around from unit to unit. I floated full time in the hospital often being pulled after working 8 hours on one unit, only to do my last four on another unit. I found it much easier that LTC's dizzying array of medications, thick gooey med pass 2.0 and crushing vs whole meds. My med pass may start at 8 and with interuptions of phones, family and patients needing help, it can end at ten or 10:30. I'd rather be slow than make an error. I've thought about getting a different job too, scary to put my license on the line. (But these residents are so nice, and they deserve good care along with good caring people.) Do what you need to do, but at least try to take the extra training ask for help and be assertive in what you need to do. Hands on med passes with back-up. Good luck. You are a good nurse, just overwhemed. If you didn't worry or tried to cover up, I be concerned.

[TriciaJ, RN]

You sound like a top-notch nurse to me, trying to function in a dysfunctional place. I got assigned to such a place by an agency once; after just 5 shifts I was burning rubber out of their parking lot.

Take the manager up on the additional orientation offer. They threw you to the wolves and they have to make up for that. But keep your eyes open for another opportunity. That place sounds like the pits.