I've been an RN for 3 years and I just made my first medication error.

getoverit, BSN, RN, EMT-P · May 24, 2008

first, sorry that happened to you. second, yes, anyone professional with a conscience has felt similarly. you mentioned that you were having an awful day...think about what things contributed to your error. are they things that could be modified or eliminated? the answer might be "no" but at least you've examined it from that aspect, and I have a feeling you've probably already thought of that by now.

My mom has been an RN for 43 years and she told me about her med error. She had been nursing for almost 2 years and she didn't notice that a heparin ampule had a different concentration from what she was used to. So inadvertantly she administered 10x the dose that was ordered. She felt so awful and tried to resign, but her manager wouldn't let her. It's a learning experience and you just need to make sure it's one of those things that only happens once.

I knew an LPN who made several medication errors and I felt like maybe she would be better suited in a job not handling meds, but that was after 2 serious mistakes and being unable to crack an O2 cylinder during a code.

You also have to let it go, there was no bad outcome and like you say, there could've been, but there wasn't. I bet you'll never do it again...I gave an incorrect med during a code about 10 years ago. Patient was already asystolic and I inadvertantly gave a bolus of Lasix instead of epinephrine. I felt terrible but the MD said "hey, absolutely no harm done and if he had been successfully resuscitated, then we'd already be on the road to diuresis". It made me feel better about it and I've never lost the caution I gained from that experience.

Hope some of this helps a little bit, just don't beat up on yourself!! Hope you have a better day with lots of sunshine!

Purple25 · May 26, 2008

I am a new nurse graduated last June and a couple of days ago I had a patient 4 days status post open heart surgery who was transferred back to ICU because of increased confusion, combativeness etc. The first night I had him, I got an order for a 1 time dose of haldol which did not help he repeatedly became confused, labs were normal, sats were fine. He remained that way for day shift, the 2nd night I had him still confused. I asked my charge nurse could i give him a prn order for morphine to help him possibly relax. She advised no, give him phenergen(which is for NV) it helps sedate and relax without the rebound affect. and he had an order for that. I gave it, 10 min later, my patient codes and his pupils are now dilated non-responsive. He still moves to touch. I had family at bedside during the entire thing. I feel terrible. I was advised by the charge nurse, er doc, attending physician it was not the medication and that he was having a brain encephalopathy that was causing his confusion and the medication just relaxed him enough to bring it out. I am a basket case and this is the first time I got a chance to just say anything about it because I have been so uptight.

In your case, nothing happened and as posted before it is a learning experience you will always have with you. You are an excellent nurse and I truly understand how you are feeling. My confidence in what I do has been shaken but reading the various post here has helped a great deal.

jayme_lee1985 · Jul 7, 2009

You've been an RN for three years and just now making a medication error? I am ashamed of myself! I have been an RN for seven months and my first medication error was as a student. I gave half a dose of simvistatin to a lady in the morning instead of the scheduled evening time. then I had the other pill (half of the dose) and realized that it was the wrong time, so held it.

It seems that I make routine non-harmful medication errors. For example, I had an order to give 0.5 of dilaudid IV q hour, once and drew up the whole mg in the syringe, thinking I would save and label the syringe. I absentmindedly pushed the whole dose. This did not result in any consequence to the pt.

Some other mistakes I have made: underdosing diflucan because I did not read the package dose carefully compared to the MAR, and realizing it later to give the rest of the dose (3 hours or so).

Giving a whole instead of a half tablet of mirapex, pushing IV vasotec over 1 minute instead of 5 (which really scared me and made me think I need to be more careful!)

Giving a 2nd post op dose of reglan too soon (3 instead of 6 hours), looking at a sloppy MAR where someone wrote beside an antibiotic "blood infusing" without retiming the drug for post blood, and not noticing it until 0400 (It was due @ 1600, before I came on). Underdosing hydrocortisone because I didn't carefully check the MAR against the home med sheet when I first should have.

And I am sure there are others. I have been concerned in the past over these mistakes, but it seems like recently I am so fed up over this. There is only one word for this kind of sloppiness and that is "careless". I am worried about my first review. Some of these mistakes I have gone to my supervisor and said, "I did this, what should I do."

I don't know what to do, it seems like it is almost part of me to be sloppy, and it is extremely distressing. I am worried that this could lead to something horrible. If I really Do not know a drug now, I look it up (like with the vasotec), but the horrible thing about that mistake is that I had seen it given before IVPB and given it that way myself at least once, so I just completely forgot. What is wrong with me and how do I change?

jayme_lee1985 · Jul 7, 2009

Also, should I even be a nurse? I understand a lot of things and I think overall I give good nursing care, but I don't know if it is I just don't have the attention to detail to pass meds correctly or what it is? Actually I have a pretty good idea that some of it is impatience and the other part is lack of attention. What is scary is not remembering, that I didn't remember that I really didn't know how to push a drug...that was truly scary and made me question myself a lot more, but I am still making careless mistakes. I probably make @ least one medication error per shift. I am really scared. I am having a hard time believing this. No one has ever gotten hurt, yet, though, and for that I thank God, but I hate this! Somebody please help!

Jolie, BSN · Jul 7, 2009

You have all posted thoughtful messages regarding the consequences (to patient and nurse) of medication errors.

These errors need to be addressed in at least 3 ways: as an employment issue (What action is needed on the employee's part to prevent future errors, such as additional education, improved oganization, etc.), as a patient safety issue (What systemic changes need to be made to prevent future errors? This needs to be a blameless system that encourages reporting.) and as a psychological issue (counseling may be necessary to enable a nurse to put the error in perspective and grow as a professional as a result.) This is often lacking. Consider consulting your employee assistance program, if one is available. If not, seek the advice of a staff educator, trusted colleague or former instructor.

orangepink, NP · Jul 13, 2009

@jayme_lee: from what i gather, u just need to be more alert and focused with your work. be present.

Melina · Jul 16, 2009

jayme_lee: my advice is to come up with a step-by-step procedure for checking and giving meds, and do not deviate from it. Personally, I check each medication three times before the patient touches it. I check the med, dose and ex. date as I pull the med from the Pxyis. Next I set the meds on the left side of the (paper) MAR, and go down the MAR, moving each med to the right as I check it a second time. If I have IV meds to draw, I check the vial at this point, then recheck my calculations before I draw it up. I label each syringe with a sharpie. In the pt's room, after ID'ing the pt, I open each pill and sign it off as I give it to the pt. It takes time, but not as much time as you might think, and I would rather take a few extra minutes to be absolutely sure. Also, if my pt is conscious, I always tell them what each pill is, and if they don't remember it as one of theirs, or they claim they took it earlier, I check the order AGAIN.

Also, if I draw more than one dose in a syringe, I never push it directly into the patient. I always add it to a flush (as long as it's compatible with saline). That way I can check what is left in the syringe before it touches the patient. I also like to attach the syringe to the pump to administer any slow-push meds (especially vasoactives), just so I know it's going in at the right pace.

Good luck, and remember to slow down, sweetie. Keep us posted on your progress, okay?

~Mel'

dumaralos · Jul 25, 2009

I forgot to give a dose of lovenox of a patient, it was a new order and the order was written during my shift but i did not saw it, then the night nurse called me, and ask if i have given the medication, i said no. I feel that I'm incompetent nurse. I have 30 patients during that shift and i was also helping in the assessment of the new admission. need advice. I feel down and anxious right now. I'm a newly licensed nurse.

morte, LPN, LVN · Jul 25, 2009

Also, should I even be a nurse? I understand a lot of things and I think overall I give good nursing care, but I don't know if it is I just don't have the attention to detail to pass meds correctly or what it is? Actually I have a pretty good idea that some of it is impatience and the other part is lack of attention. What is scary is not remembering, that I didn't remember that I really didn't know how to push a drug...that was truly scary and made me question myself a lot more, but I am still making careless mistakes. I probably make @ least one medication error per shift. I am really scared. I am having a hard time believing this. No one has ever gotten hurt, yet, though, and for that I thank God, but I hate this! Somebody please help!

if i were ye, i would consider getting eval'd by neuropsych for ADD....this is NOT meant as an insult...

learning08 · Jul 28, 2009

It happens. Don't sweat it. It was caught, and surely the night nurse gave it. You are not an "incompetent nurse"--you are only human. This is a minor med error!

I forgot to give a dose of lovenox of a patient, it was a new order and the order was written during my shift but i did not saw it, then the night nurse called me, and ask if i have given the medication, i said no. I feel that I'm incompetent nurse. I have 30 patients during that shift and i was also helping in the assessment of the new admission. need advice. I feel down and anxious right now. I'm a newly licensed nurse.

jayme_lee1985 · Jul 29, 2009

Hey Mel. Thanks for the post...things seem to be going better. I talked to my boss about this and she said just do not get in a hurry. She said to make medications my priority right now and slow down and take time for them. I agree and it seems to be helping. I missed one thing the other night, and ended up catching it and retiming the schedule.