med error on first shift

  1. Hello everybody, this is my first post on this site

    I am a brand new grad and just started a job at a LTC home. I had my orientation shifts and had my first shift on my own yesterday from 3-11.. Unfortunately it was a stressful shift.

    During my shift I had experienced my first med error...... I had given a patient the wrong medication (resident received the medication intended for another resident with the same name). These were the events leading up to the error:

    My laptop on the med cart died during the med pass (nurse before did not plug it in) therefore I was looking at the EMAR from the computer at the nurses station at the front of the home.. preparing my medications with the cart there, then taking them to the resident. I had in my head I was giving the medication to James Doe, so in my head I kept saying James. I was walking down the hall and seen "James" on the door tag, so I approached that resident asked their name and proceeded to give the medication. Then when I went back to the computer I realized it was the incorrect James.. The James I had given the medication too had a nickname on his room tag... His correct name was somethign other than James but liked to be called that.

    I had given the wrong James, dilaudid 1mg and a dose of eliquis (cant remember dosage) I IMMEDIATLEY called the ADOC (assistant director of care) and she came and helped me through the process. Telling me it was ok that everyone made mistakes. We informed the family and the doctor and everything was ok... but I still felt terrible. And am really doubting my ability to practice nursing.....THe patient remained stable and was in good spirits.

    If the resident's had their proper names on the door tag would the med error not have happened, if my laptop died would it not have happened? I don't know. All I know was I made and error, even though there were circumstances leading up to it, I still am seriously doubting my ability.

    Are medication errors reported to the board of nurses/College of nurses??
    Should I continue to beat myself up about this error, or move on from it and learn frrom this mistake?
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    About patcheslatches

    Joined: Aug '16; Posts: 3


  3. by   Ruby Vee
    Everyone makes mistakes. Everyone. Anyone who tells you they haven't made a mistake is either lying or too stupid to realize that they've made a mistake. Making a mistake doesn't make you a bad nurse. What makes you a bad nurse is lying about it, trying to cover it up or being too stupid to notice you've made a mistake in the first place.

    A GOOD nurse recognizes a mistake, informs those who need to know about it and immediately sets about mitigating the consequences to the patient. It sounds as if that's exactly what you did.

    It's easier said than done, but don't beat yourself up. Learn from it, figure out how not to let it happen again and move on.

    There's a thread on here somewhere about the "worst medication error you've ever made." There are some doozies on there, but the good news is that if you do the right thing, patients can survive even a spectacular doozy of a medication error. I've made some doozies myself; we all have.

    Back in the days when everyone got Demoral and Phenergan IM as a pre-op for surgery, I got a call from the OR that Mr. Robert Johnson was to be given his injection and sent to the OR. I gave the meds to Mr. John Robertsson. The OR was royally ticked off that Mr. Johnson wasn't ready when they came to get him, and Mr. Robertsson had a really nice, long nap and couldn't be aroused enough to sign the consent for HIS surgery which then had to wait another day. And I felt about like you did -- beat myself up about it for weeks. Finally, my head nurse sat me down and said "Listen. We all make mistakes. What matters is what you do AFTER you make the mistake."

    There's a thread on that, too. I know because I started it. I think it's called "What to do after you've made a mistake." I can't figure out how to link it on my phone, but you probably have way better internet skills than me.
  4. by   BuckyBadgerRN
    I get what you're saying!! I do a casual position in ltc and can think without even trying SIX residents whose legal name is not what they like to be called. The tag on their door says "dick" but in the mar they are "richard". And that's an easy one! We've got residents with nicknames not even close to their legal names. Also, down one hall there are FOUR Betty's, I kid you not. It's a 75 bed facility and they loaded up one hall with four of the same name!
    med errors happen. To everyone. Anyone who says they haven't are either too new or liars. Hopefully your facility can identify the breakdown of yours and take steps to prevent another one given the same situation!
  5. by   oncivrn
    I've never seen anyone censured for one med error on one day. It's a pattern of sloppy work they look at.
    I once mixed up two chemo rates on a patient. I felt horrible and the doctor was mad of course. But the patient was fine and went on to go into a long durable remission.
  6. by   quiltynurse56
    As has been said, we all have made med errors. The fact that you recognized it right away and asked for help says a lot. You are going to learn from this and become a great nurse. First thing is to make sure the computer is plugged in when you take over. I don't know about where you work, but if there a plug ins along the wall of the hall, you can plug it in along the hall too.

    The important thing here is that you take and learn from this experience and take steps to prevent it from happening again.

    I think that part of the reason we panic when we make a med error is that it is pounded into us in nursing school that a med error is an end of nursing career sort of thought. When we get out and make that first med error, we have that mindset, only to be told that is not the way it is in the real world.

    Keep up the good work
  7. by   GreenOne
    LTC is difficult compared to med/surg in my experience. You have more patients. The meds are preloaded in that huge cart you push around not the pyxis. The residents probably don't know or remember their meds. Some don't know their own names. The one I worked at, they didn't wear name bands. So much potential for med errors. I agree with what everyone has said, you recognized the mistake right away & took appropriate action.

    I think you can always judge a facility by how management reacts to med errors & it sounds like you have a good one.
  8. by   9lives
    It's a horrible lonely feeling. Many nurses make errors and learn from them. I'm sorry this happened!