Med Error Question

  1. I inadvertantly gave 0.5 of a Lortab regular strength to a patient. The order was 0.5 of a extra strength.

    I followed my error with an incident report, and now my standing in med administration is in jeopardy. (We have strict rules on errors.) I was made to complete a 7 page error booklet and sent to another division to take vitals.

    The med was the same, just less than what was ordered. What do you think?
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    About cnolan

    Joined: Jan '05; Posts: 78; Likes: 9

    23 Comments

  3. by   sanctuary
    It is tempting to say "No big deal" except that all med errors are errors, and as such, serious events. Did the patient suffer harm? No. Is the system in place to make you more carefull about every dose you pass? Yes. BTW, ain't none of us who have not made an error. Yours is a benign one. Be thankful and use it.
    Last edit by sanctuary on Apr 3, '07 : Reason: spelling...again.
  4. by   TazziRN
    Seems like a heavy-handed way to deal with errors, but if that's the facility's policy then it has to be followed. Be relieved that you erred by underdosing and not overdosing. Just learn from this experience and go on.
  5. by   meownsmile
    Med errors are serious, but i agree their reaction was a bit over the top. Just learn from your error and go on. If they jump to disiplinary action because of a no harm error i guess they arent short staffed like most places.
  6. by   BittyBabyGrower
    Wow..that is over the top. All that is going to do is make people NOT report their errors.
  7. by   miko014
    Wow...all that for an error like that? But it depends on how it was caused, I guess...how did you get the med? I mean did pharmacy send up the wrong kind and you gave it because it was there and it said "lortab" on it? Or do you have that in a pyxis or similar machine? If so, then the pts order should have been the only one you could choose (e.g., if the pt is ordered extra strength, then the regular shouldn't even show up under his/her profile). Yeah, you did notice it after the fact, but like they say, it's usually the system that causes the problem. Was it becasue you didn't follow policy? Like, if you use the computer and you are supposed to scan the pt and scan the med, but you gave the med first and then scanned it and realized what you had done, then I could see them wanting to make sure that doesn't happen again. But kudos to you for reporting it - a lot of people wouldn't.

    We had a nurse hang a bag of heparin (25,000 units in 500 ml) over one hour on a pt 'cause she thought it was vanco - and that wasn't even the pt who was supposed to get the vanco! And I don't think she ever got more than a lecture about being more careful for that. THAT was a bad one. Be thankful that yours didn't cause any harm.
  8. by   karenna
    Quote: "I followed my error with an incident report, and now my standing in med administration is in jeopardy."


    You made an incident report about this?! A freakin lortab?!! Get real. Stay in this field long enough and you're bound to make more mistakes. I have worked so so so hard on hospital floors, knocking myself out trying to take care of everyone, staying hours after my shift was over to nurse the paper work, putting on the happy nurse face for patients and families when I just wanted to run away from the hospital and never come back.. Girl, med errors just happen. Best to keep med errors to yourself and hope for the best. Think I'm a bad nurse? Well there's lots more like me where I come from.

    Left the hospital scene in 2003 after 12 years of misery and ain't never going back.

    karenna

    Quote:"Wow..that is over the top. All that is going to do is make people NOT report their errors."

    Ya think?
    Last edit by sirI on May 7, '07 : Reason: TOS
  9. by   smartynurse
    this was a benign error...i have made mistakes too..i also was penalized for it very harshly, even though i did all the right things...just learn from it and pick your battles...if you make a major mistake, own up to it, but i'm sorry, if it was that minor, i think i would not report it, sounds like that facility is antiquated in it's approach to med errors, so be judicious in how you respond to that.. you did do the right thing, and you are human!
  10. by   jetscreamer101
    There are policies in place for a reason. Knowing what will happen with errors kinda keeps you vigilant and not as likely to repeat an error. The other day, I stopped by a room as the nurse was hanging a piggyback of cipro, and I asked her if she was sure that was what was hanging (I read the label). Nope, it wasn't. She said something like "I know you're supposed to check the label, but I didn't". ?????
  11. by   Creamsoda
    I probably wouldnt have reported that error either. But say if I gave double the dose, and forgot to cut the pill in half, I would have reported that because too much would have been worse that too little. Technically every little error should be reported, but im sure that doesnt happen in the real world.
  12. by   zacarias
    the problem is, this nurse who reported this error dutifully when many wouldn't have, this nurse is now "labeled" in a way as a risk. Non-punitive reporting...please...
  13. by   ginger58
    Sent to another unit to take vitals!! What kind of sorry excuse is this for nursing policy? I understand the gravity of a med error but if hospitals want to retain nurses, they need to be a little less punitive.
  14. by   canoehead
    If you gave less than was called for I would be inclined to just go get more medication and give it to the patient to make up the difference ASAP, and forget the error part.

    They do seem a bit heavy handed, that's for sure.

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