OMG - Gave meds to wrong patient

Nurses Medications

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It was a busy night full of distractions and frustrations. Twenty three patients and not enough time. Then it happened! I exited the patient's room: wait something is wrong! Something is off. The color of the pills? Oh ****, my heart sinks, and my knees weaken. I've just made a med error - I gave a resident someone elses meds.

Has this happened to you? What did you do? Did you report it? Or did you remain silent for fear of losing your job?

TheCommuter, BSN, RN

102 Articles; 27,612 Posts

Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

We use an electronic MAR in which the patient's armband must be scanned prior to scanning each pill, so these types of medication errors no longer occur at the facility where I am employed. If the system is not allowing a nurse to scan the pill, it is because the pill is not on the patient's medication profile.

I assume your facility still uses a paper MAR.

JustBeachyNurse, LPN

13,952 Posts

Specializes in Complex pedi to LTC/SA & now a manager.

Of course you report it so that a process evaluation can be done and corrective action implemented to prevent future occurrences. Id be more afraid of losing my job for failing to disclose an error that could have resulted in patient harm. What if there is an adverse effect and no one knows the patient was misdosed and proper therapy is not instituted?

RN403, BSN, RN

1 Article; 1,068 Posts

Report it. Staying silent will do nothing but cause harm. It could potentially cause harm to your patient and could potentially cause harm to you in the future for covering up what happened. Report the issue, which I hope you have by now, and learn from your mistake.

Also, by reporting these types of situations, changes can be made to prevent such errors from occurring in the future.

Unfortunately, a med error to some degree will occur with most if not everyone at some point. Even with electronic medication administration, things happen. You are not alone,you are not the first to make a mistake, and you will not be the last.

MrChicagoRN, RN

2,597 Posts

Specializes in Leadership, Psych, HomeCare, Amb. Care.

Report it.

You actually should have reported it as soon as you realized it. Not only did the patient get the wrong medication, they also did not receive the right ones

Take a fresh vitals, call the doctor, be apologetic, ask what they'd like to do, fill out the incident report, notify your charge nurse or manager.

It's happened to just about everyone, including me, and the normal reaction is to feel horrible. You also need to think about what you need to do differently to prevent this from happening again

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