Near miss

  1. I just transitioned to a peds cvicu from an adult cardiac step down. On my first shift (with a preceptor), I went to switch out a syringe for one of the medications that was running out. I accidentally grabbed the wrong syringe. As I was programming the pump and trying to figure out with my preceptor why my gtt rate wasn't matching up, I realized I had the wrong medication. Ugh I felt so horrible! My preceptor was very nice about it but I lost my confidence as I am way better than that.

    I always scan in a med before administering but for some reason I did not do that this time. After that, I made sure to scan in everything first and to double check all meds with my preceptor. Like everyone else, one of my worst fears is doing harm to a pt.

    Luckily these drips are always double checked by another nurse anyway but I have been feeling horrible about it for the last few days...
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    About Lame, BSN, RN

    Joined: Jun '11; Posts: 223; Likes: 79


  3. by   ChryssyD
    You're human! A near miss today makes for a more cautious nurse tomorrow. You learned from it, that's what matters. And ALWAYS double-check any high-risk drugs.
  4. by   offlabel
    The more drugs you handle, the more likely a near miss is. I've lost count the number of near misses I've caught. The only defense against an actual error is to develop the habit of being mindful, deliberate and intentional about every single thing you do from emptying a Foley to hanging a hi risk mediation to flushing a central line.