Nurses make easy scapegoats when it comes to finding someone to blame for mistakes

BlueDevil,DNP, DNP, RN · Jun 24, 2012

I am certain I made errors that I never realized were errors. The only medication error I know about is once having given topamax instead of toporol, it it may have been the other way around, I can't really recall.

As a NP the mistakes I am aware of having made have all been on the side of caution, or harmless ones stemming from inexperience. I have ordered the wrong set of xrays (and thankfully the techs always called and explained to me what it should have been), too many lab tests, etc. To my knowledge, I have not made any serious errors that posed an immediate safety risk.

NO50FRANNY · Jun 24, 2012

That, was a very sad story. I pride myself on safe administration of medication and have my own little system that I've developed over the years. To my knowledge, up until a couple of months ago, I had never, EVER, made a wrong patient (or any other kind) of medication error. I spend time with new-grads re-iterating how important safe medication administration is, and giving them tips and advice. To cut a long story short, recently, I was the resus team leader in ED overnight. We had 3 nurses altogether, 5 patients in resus bays and a trauma had just been unloaded. I sent my other two team members in to work up the trauma patient and covered the others myself. Two of the patients were vascular admissions with limb ischaemia and heart problems. One had a TNI leak and the other was in rapid AF and was receiving titrated IV metoprolol (betaloc) for rate control and I was not the primary nurse for either patient. We often receive verbal drug orders in resus and the medical registrar asked me to give "this patient" while holding a chart up in front of me, some oral metoprolol. He was asking me this in the bay with the lady who was having IV betaloc. Guess who I gave the oral metoprolol to?. The wrong patient. He had shown me the chart for the other lady he was admitting with the TNI leak (he was admitting both patients, essentially at the same time).

I was almost inconsolable when I realised my error. I didn't follow the 5 rights, however it is easy to see how this error occurred. Both the ED registrar and the medical registrar almost laughed at how upset I was when I reported it, stating that it would most likely "fix her" and not to worry. Fortunately we have a non-punitive system for incident reporting and strategies are being devised currently to prevent something similar happening again. I made the suggestion that we only act on verbal orders from emergency physicians while patients are in resus amongst other things. Fortunately my error did "fix" the patient but I was just lucky. We need to continually re-assess medication safety as a team and look at all the factors. I can't speak for the nurse mentioned in the OP, but I probably couldn't have lived with myself either. In Australia, all paediatric dose / drug administrations are a two RN check at the bedside, regardless of type of drug or route, maybe this incident was preventable.

xoemmylouox, ASN, RN · Jun 24, 2012

I think that mistakes happen. No one is perfect. Should she have lost her license, no. Should she have to do some sort of medication education, yes. Doctors make mistakes, but often are not forced to loose their license. It is a reminder to all of us. Do not become in a routine. Double check all medications. CYA.