Almost made a very bad med error today

AJJKRN · May 19, 2015

I am very blessed to work for an entity that does not penalize nurses/staff for reporting actual events or near misses (unless the incident is out right blatant or the person that made the error can not see any of their own fault in it if they were reasonably or obviously in the wrong). I hope that you work in an environment where you would feel supported if you chose to report and hopefully pave the way for system changes/education. (((Hugs)))! Maybe handouts could be made on the drugs that are commonly mixed with numbing agents for injection use to give the Pt prior like vaccine information handouts are or who ever checks the Pt in reviews their allergies each and every visit. Why not, we ask every Pt every admit now if they've been exposed to Ebola or have been on a recent cruise even if they just got admitted from an ECF. :roflmao: But hey, if it might save lives and increase response time to treatment/isolation then it's worth it right?

dudette10, MSN, RN · May 19, 2015

Thank you for sharing this. Yes, do a near miss incident report to 1) encourage allergy check and documentation at each admission/office encounter and 2) increase awareness of checking allergies to things that don't have to go through the pharmacy check/doctor's orders like numbing agents, antiseptic agents, foods, and medical device materials.

klone, MSN, RN · May 19, 2015

No, my facility does not penalize for honest errors, and I always look at incident reports as a process improvement opportunity. As the charge nurse, I fill them out regularly because I'm the one that staff and patients come to with issues and problems. Just haven't had to do one on myself in a while!

Thanks for the feedback! Will fill one out in the AM. We have a staff meeting tomorrow, so it will be a good reminder to staff to ask about and update patient allergies at every visit.

Lou7 · May 20, 2015

Hi Klone,

I can completely understand how you are feeling! Its awful when you nearly make a drug error, worse If you actually follow through with administration. You sound like a very conscientious nurse and were very honest and open to your patient which is exactly what is asked of every nurse from the NMC. So well done. I think the word here is 'almost'. It was almost a mistake but instead it will just serve as a little reminder for you in future to make sure you know of the patients allergies before preparation of the medication. Its so easily done so don't worry. I wouldn't class this as an error or even an incident but if you feel very worried about it speak to someone in charge who might know what the policy is. If it makes you feel any better, I had a situation one evening when I went to a patient who was self medicating and checked with him that he had had all of his night time medication. He said yes, but that he hadn't taken his antibiotics. I said I would get this form him and I came back with his medication. I did my checks and he took the tablet. He then told me straight after, that he had had the tablet! I was mortified! There was a few things wrong with this incident. The patient was clearly not competent to be self medicating and the drug kardex did not match his medication regime that he had. I told him what had happened and he said 'Oh that's my fault, im sorry' I said I would need to fill an incident report in because he now had been given too much medication. The patient said 'Oh don't be silly its only one tablet, im not going to say anything. Itl be our secret'. I told him I had a responsibility to look after him and be honest in my profession and I would report the incident. My fellow staff nurses didn't feel I needed to write an incident report and I wasn't told off, but it was a lesson for me that its so important to make sure patients understand their medication regimens and that the kardexs match. Also, properly assessing patients to whether they can self administer their own medications.

I've met nurses that have made worse mistakes than you. Trouble is we are only human, and we will make mistakes. The important thing is that we learn from them and use our experience to guide our future :) You sound like an amazing nurse, so let this pass and smile :)

Louise xxx

xoemmylouox, ASN, RN · May 20, 2015

As usual another almost med error that was caused by a domino effect. Whoever has recently been in that person's chart should have updated her allergies & medications. It is VITAL to ask at every visit/phone call as these things change daily. That started the whole problem. I would write up a report or at least emphasize just how important it is to update this in a pt's chart EVERY time someone is in that chart and with the patient. Good catch.

HenryBood · May 22, 2015

Great responses, great post. I think that your integrity and conscience are the backbone of what makes a nurse a Good nurse. Everyone makes mistakes, and you following through to report a near miss could stop the next nurse from making the same mistake- especially a mistake as easy and as common to occur. That is how policy and procedure and best practice is constructed- from the making and thus following through on incidents such as this.

Oedgar · May 23, 2015

Thank you for posting this. It will serve as a reminder for me the next time I give a Rocephin. I think perhaps you should write a report, so everyone can be diligent about having the current allergy info on the chart. There is an issue at my office of when new patients come and fill in their info... and leave the allergy list blank instead of writing 'no allergies." The the front office puts the chart together, with NKDA listed on the front of the chart. Several times I have gotten the patient back, actually asked the patient about allergies... and guess what? They are allergic to something. I know you feel bad.... I hope in time you can just be thankful for the fact that you did NOT give the drug. How was the patient with this?

AdamantiteEnigma · May 24, 2015

I'd absolutely fill out an incident report. If that patient had allergies that weren't listed in the chart, not good. The opportunity for process improvement, better outcomes exists.

Thank goodness for verbose patients, eh?

Carpediem1012, BSN, RN · May 25, 2015

Isn't ceftriaxone contraindicated for those with penicillin allergies as well?

CaringGerinurse525 · May 25, 2015

Cephalosporins can be prescribed safely for penicillin-allergic patients. - PubMed - NCBI

Carpediem1012, BSN, RN · May 28, 2015

Interesting. Thank you!