Has anyone made a medication error and *not* get fired for it?

[pinkiepieRN]

I screwed up tonight, plain and simple. I had meds pulled for two patients and started giving meds to one patient. I pulled the pills in their packages out of the cup and told him each med and their dosage. The second after he put the cup to his lips, an "oh ****" comes out from under my breath. I realized that what I had given him was intended for the other patient and that I had made an error. I walked back to the nursing station, told another nurse, told the charge nurse, called the doc, got an order for Benadryl to prevent any undue reactions, however unlikely, filled out an occurrence report, documented in the chart (without saying it was an error) and made it through the rest of my shift. Everyone was telling me that it was okay and I did the right thing, but I'm terrified. I'm thinking about calling my supervisor in the morning and admitting my screw-up before she gets the wrong idea. Is this nuts?

[sissiesmama, ASN, RN]

I know I've definetly made some. The worst was crushing the pt's routine meds and giving them via G tube...

Right meds, right pt, but the tube I pushed meds they was not a PEG but a foley type DRAINAGE tube to the abdomen.

I had gotten in report the pt had "a tube" and we were crushing meds to give.). Pt was NPO except meds.

Having to make that call to the MD was brutal - I was SO embarrassed! Thank God the pt had no side effects from my error - that would have just pushed me over the edge.

The only time I can remember a nurse getting fired due to a med error -- got an order to give a unit of PRBCs - went to the lab to get it - checked off the unit with the slip that came with it at the nurses station and went down to the pt's room. Didn't have anyone to come down to check the armband at the bedside.

Hung the blood in that room (room was semi-private) but started the transfusion on the wrong pt - she didn't even notice it until she went to get another set of vs.

Talk about a nightmare!

Anne, RNC

[Hoosier_RN, MSN]

We've all made mistakes, whether we admit it or not. And we've all lived to tell the tale, and provide care another day. Use your 5 (6) rights each and every time, and you'll be fine. Own up to, and learn from, any mistakes.

[skylark, BSN, RN]

sissiesmama said:

I know I've definetly made some. The worst was crushing the pt's routine meds and giving them via G tube...

Right meds, right pt, but the tube I pushed meds they was not a PEG but a foley type DRAINAGE tube to the abdomen.

I had gotten in report the pt had "a tube" and we were crushing meds to give.). Pt was NPO except meds.

Having to make that call to the MD was brutal - I was SO embarrassed! Thank God the pt had no side effects from my error - that would have just pushed me over the edge.

The only time I can remember a nurse getting fired due to a med error -- got an order to give a unit of PRBCs - went to the lab to get it - checked off the unit with the slip that came with it at the nurses station and went down to the pt's room. Didn't have anyone to come down to check the armband at the bedside.

Hung the blood in that room (room was semi-private) but started the transfusion on the wrong pt - she didn't even notice it until she went to get another set of vs.

Talk about a nightmare!

Anne, RNC

For the first incident, it sounds like a poor reporting/communication scenario. Many facilities use foleys as temporary g tubes when the patients pull them out, so I can't see that you would have been able to tell the difference without correct and complete information.

As regards the second incident, there is never any reason to transfuse without the correct checking procedures, involving TWO nurses. Even in an emergency where the pt is unconscious and has not signed consent, two nurses should still check ID, wristband, etc and verify properly.

It takes half a minute of the second nurses' time and even if they are doing chest compressions at the time, they can still read the ID and confirm it! I have done that many times in ER, the first nurse holds up the blood bag and form in my field of vision while I continue CPR, and they check the wristband and order and read it to me.

[sissiesmama, ASN, RN]

skylark said:

For the first incident, it sounds like a poor reporting/communication scenario. Many facilities use foleys as temporary g tubes when the patients pull them out, so I can't see that you would have been able to tell the difference without correct and complete information.

As regards the second incident, there is never any reason to transfuse without the correct checking procedures, involving TWO nurses. Even in an emergency where the pt is unconscious and has not signed consent, two nurses should still check ID, wristband, etc and verify properly.

It takes half a minute of the second nurses' time and even if they are doing chest compressions at the time, they can still read the ID and confirm it! I have done that many times in ER, the first nurse holds up the blood bag and form in my field of vision while I continue CPR, and they check the wristband and order and read it to me.

Right! When I gave those meds thru the foley, as soon as I realized what I had just done, I thought I was going to be sick! As my hubby said, kind of a "comedy of errors" type thing. Info could have been better in report, I should have asked more questions, and that type of thing. I was SO thankful that the pt wasn't hurt.

As for the blood, there was NO way any of that should have happened the way it did! Transfusions have never been something that I enjoyed doing - I get a little "overly cautious" with them hubby says. I don't know what that nurse was thinking - I guess she wasn't thinking at all - in a million years I don't think I could pull any rationale from my ____ that would explain what she thought she was doing.

Like u said, even in the ER with a trauma that doesn't happen. No excuse for what she did - she got terminated when this happened - she ended up in a lot of trouble with the BON and is no longer nursing - she got caught diverting narcotics and refused to comply with her board stipulations.

Anne, RNC

[Alicianurse]

I made a drug error last week. It was my first error and I had nothing in my file. I was fired the very next day . I was in shock over this. I gave the wrong patient a percocet. The MD was notified and no harm was done to the patient. I was called in and told that this was considered a sentinal event and was cause for termination. I've been a nurse for 20 years and have never see a nurse fired for a mistake. I was given no warning and was terminated. I feel as though I have been judged unfairly.

[Penelope_Pitstop, BSN, RN]

Alicianurse said:

I made a drug error last week. It was my first error and I had nothing in my file. I was fired the very next day . I was in shock over this. I gave the wrong patient a percocet. The MD was notified and no harm was done to the patient. I was called in and told that this was considered a sentinal event and was cause for termination. I've been a nurse for 20 years and have never see a nurse fired for a mistake. I was given no warning and was terminated. I feel as though I have been judged unfairly.

"A Sentinel Event is defined by The Joint Commission (TJC) as any unanticipated eventin a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness."

So nope, not a sentinel event.

Either there is more to the story, this didn't really happen, they're complete idiots, or they're out to get you.

[goldline]

I have only been a nurse for 3 months and last night I made my first med error. I received a call this morning that I was terminated. Ironic that I gave my resignation notice at the start of my shift yesterday and now today they fired me. Their reason for terminating me was because of the med error, and my termination would start as of today. This was my first nursing job and I was only given 5 days of orientation.

[natalieann1989]

Hi I am a support worker in associated living I poped the wrong medication out of a blister pack put it into a glass and went to tip it in there mouth but they didn't take any of it it only reached the til of the lip I realised straight away but when asked I told my boss no I didn't but the same day I rang her up and explained I did and that I was scared because I already had my probation extended because someone was saying I broke confidentially but I hadn't. I'm really scared I don't want to loose my job but think I will I don't no what will happen to me

[natalieann1989]

Hi I am a support worker in associated living I poped the wrong medication out of a blister pack put it into a glass and went to tip it in there mouth but they didn't take any of it it only reached the til of the lip I realised straight away but when asked I told my boss no I didn't but the same day I rang her up and explained I did and that I was scared because I already had my probation extended because someone was saying I broke confidentially but I hadn't. I'm really scared I don't want to loose my job but think I will I don't no what will happen to me

[D00D00]

Well said.

[TravelinRNurse]

I am a new-grad and have made several mistakes. I even suffered through my boss telling me I was over-confident, which blew my mind because I knew I was scared and paranoid of error on every shift. I was further shocked by her comment when, throughout my orientation, I told everyone who would listen that I felt very unprepared to carry a 5-patient load.

Three mistakes I've made so far: I set the rate of a NS bag to 950 for 75 mL instead of 75/hr of 950mL. Noticed that right away...it was never a problem, and I hope I never repeat it! I gave a whole BP pill to a patient instead of a half when dysphagia came in started asking me questions just as I was taking the pills out of their packets. Now I know to highlight the back of anything that needs to be split, or to split it and discard 1/2 before I go into the patient room. It wasn't a dangerous situation, but her BP did drop which scared the patient. I felt bad that something I did contributed to her stress. I let the Dr. know right away. Another mistake was that I gave a vasodilator with parameters of Systolic under 110 to a patient with Systolic of 101. This mistake was a combination of reading the number wrong and being so used to dealing with patients with HIGH BP that I neglected to recognize the significance of LOW BP... as well as a condition of over-thinking an issue with his Aspirin Rx. I should have made these decisions in the substation instead of in the patient's room with all the distractions. Again, got Dr. on board ASAP and a couple of NS boluses fixed his drop in BP. I was scared out of my wits though.

Overly confident? Definitely not. Naturally careless... maybe.... but I'm really working on that... trying to be more OCD about every. little. thing.

I, too, was left wondering whether or not I'm cut out for this job, but the other nurses, when I share my mistakes, just look at me straight-faced and share good advice about how to prevent errors like that. In the back of my mind I always wonder if they are looking at me like "you big dummy" and talking to each other about what an idiot-nurse I am, or how I'm not cut-out for this line of work, or other self-defeating thoughts... but more likely, they are rooting for me and thinking back on the mistakes they made when they were new too.

[phoebe2020, BSN, RN]

I haven't made any serious med errors- YET!- but damn, I've had a few near misses. One happened the other day at the end of a night shift - we were running behind all night and to help the oncoming shift, I prepared some antibiotics for two patients in the same room. I told the AM nurse they were ready for her to hang, and she was still busy. It was past my home time, but I felt bad for letting these drag onto her shift and they were technically supposed to be given now, so I went to hang the first antibiotic. She came in and said "no!" and just as I was about to hook up some flagyl to bed A, I realised that the flagyl was meant for the patient in bed B and the cefazolin was meant for bed A!

That scared the living daylights out of me. I looked at the nurse and I said, "I'm going home to sleep." I was shaken, because this patient also had A LOT of documented allergies. Flagyl wasn't one of them, but who knows? It was still the wrong drug. I've only been nursing a few years, and I've had nightmares about giving the wrong med, and I hope and pray I never make a serious med error. But lesson learned...