Med error

[NurseD0816]

So... I made my first med error today... a big one. I am new to nursing, been a nurse for a little under 10 months. I was asked to come in and cover 4 hours today for a sick co-worker. I walked in to a patient in the ED complaining of chest pain. My coworkers had started the ER and I jumped in to help right away; I took over the ER after getting report for my other nurses and waited for further orders from my provider. Long story short, I was ordered to hang a heparin infusion (which I have done before) and give an initial bolus of 4000 units... I calculated the concentration which came out to be 25,000 units/ 250 ml D5W. I called my provider to check the rate to be hung and was ordered to give 12 units/ kg which in the this patient would be 1146 units. I did the math while on the phone and double checked with the provider. I got up, walked into the ER and hung that bag.... at 1146.....1146 mls..not units. I poured that bag of heparin into my patient...

I realized my mistake shortly after when I was looking the MAR to prepare my report for the receiving facility.... My stomach just dropped... As soon as I saw the ordered rate I just about puked... I can't believe I did that...

I picked up the phone, called my provider and owned up to what I had done...Trying everything in my power to not burst into tears on the phone. Mean while, I am looking at my patient, scanning for any signs of my mistake. Vitals are good, BP still elevated, but not any higher than initially.

My provider handled it better than I would have if I were him. He called the cardiologist for orders - I was told to just monitor for signs of bleeding. The patient remained completely stable while in the ER and was transferred without problem. I followed up with my provider after the incident and discussed my areas of improvement.

The thing that upsets me the most is that I have literally no excuses! I was not tired, or side-tracked. I was not any busier than any other day, in fact it was a pretty mild ER considering. I had staff members available to help me, and I had even double checked my order with the provider! This was not a new task, I had mixed and calculated heparin drips before. I was not overwhelmed or having a bad day... I just simply made a mistake...

I have been crying for hours now... I know the patient is ok, and I am thankful. But Lord, I do not want this one mistake to ruin my career. Any advice from some seasoned nurses?

[bgxyrnf, MSN, RN]

I'll start with, "Hi, my name is KindaBack and I was involved in a serious medication error."

So, niceties out of the way...

You need to get clear on high-alert medications and *why* they are mandated to have an independent double-check. Heparin and insulin are the two top dogs on the list if for no other reason than we give 'em all the time. Except in an acute STEMI, heparin is not a time-critical med; there's no reason to ever, ever skip the double-check.

This error does reveal a lack of basic knowledge about heparin as well as basic med practices. At the moment I cannot think of any medication that is dosed by volume; most of 'em are dosed by mass (mg/g) with the few exceptions such as heparin and insulin which are dosed in units. Additionally, typical heparin doses are 4000-6000 units as a loading dose and in the neighborhood of 1000 units per hour.

Did it not trip some alarm bells in your head when your dose came out to be more than 4 bags of heparin? Very, very few meds require multiple vials to administer the dose. Getting an answer such as you did should trigger the "is this reasonable?" question for you... which is something that I urge students to apply to every answer that they get.

I'm also a bit confused about the provider response... the patient was just loaded with dose of heparin 10x - 100x the appropriate dose and they didn't order immediate reversal and transfer of the patient to the ICU for close monitoring? Perhaps I'm misunderstanding how much heparin the patient actually received.

Here's my advice, from someone who's made a serious med error:

1) Learn, learn, learn... why did this happen? There are two root causes: (a) not following standard protocols requiring an independent double-check, and (b) lack of knowledge/experience with the drug. Make sure you never let either of those issues happen again. Always double-check and always be certain that you know your drug... you can't fulfill the five, six, seven, or eight rights of med administration if you're not intimately familiar with the drug.

2) Don't beat yourself up over it. You made a serious mistake, true, but that makes you a safer nurse in the long run. I use this analogy: When I was a young pup, I crashed my motorcycle due to recklessly riding way above my skill and experience level. Afterward, when I would ride again, people would express concern about my riding. I would always reply, "Are you kidding? I'm now the safest rider that you'll ever come across because I *know* how bad it can go and how quickly." It's the same with the med error... if you do a root-cause and make the fundamental change, it's quite likely that you will *never* make another med error.

[Mavrick, BSN, RN]

My concern is it didn't trigger a little bug in your brain when you were setting a drip (or any fluid really) for a rate of over 1000ml/hr. Most IV pumps won't even go that high.

Same if you ever had to open 13 vials of any kind of medication to get the dose you calculate. Most drugs are so packaged that you don't need to open more than 2 or 3. If your calculations work out to some bizarre number, check with another nurse.

Take mistakes seriously but most important learn what may have caused the mistake in the first place. We all make mistakes but we try to minimize them as we gain experience in how to avoid making them.

Keep an eye on the big picture.

[BSN16]

Where was your second verifier prior to starting your heparin and/or are you in the U.S?

not all facilities require this. I came from a facility that required a witness to put in their id/pw for many drips such as heparin/fent/etc....

I actually just moved to a very well known teaching hospital that does NOT require a witness. Yes OP made a mistake and owned up to it and did everything right after noticing the mistake. I can tell they feel horrible about it and learned their lesson. No need to make them feel worse when they probably came here looking for advice.

[NurseD0816]

We now have a written protocol requiring 2 nurses to verify a heparin drip, etc. Not only will I be following this protocol personally, but I will also make sure to double check all orders prior to administration of any med, utilize the bar code system to the best of its ability, and really truly stop following the "crowd". Just because this is the way some nurses practice, does not make it ok. I learned this lesson by making a huge mistake - I am going to look at this as my wake up call - it is my nursing license - I will be practicing in the most prudent manner I possibly can from here on out.

[bgxyrnf, MSN, RN]

We now have a written protocol requiring 2 nurses to verify a heparin drip, etc. Not only will I be following this protocol personally, but I will also make sure to double check all orders prior to administration of any med, utilize the bar code system to the best of its ability, and really truly stop following the "crowd". Just because this is the way some nurses practice, does not make it ok. I learned this lesson by making a huge mistake - I am going to look at this as my wake up call - it is my nursing license - I will be practicing in the most prudent manner I possibly can from here on out.

Bravo.

One bit of your thinking that could stand to be tweaked:

I am going to look at this as my wake up call - it is my nursing license - I will be practicing in the most prudent manner I possibly can from here on out.

IMO, it's not about your license... it's about the patients who have entrusted themselves to your care.

[chare]

[...]

IMO, it's not about your license... it's about the patients who have entrusted themselves to your care.

So true, and so unfortunate that many seem to forget this.

[KIMMIEKAY11868]

We are not God. We are human so we will make mistakes. Don't beat yourself up. You learned a lesson and you can even use this to help new grads!