I was curious if some experienced nurses can help me or give tips/advice. I am a nurse with about 6 months of experience. I work in oncology. I have had two med errors since starting, nothing that has done much harm, but I feel guilty and wanted to see if there was a way maybe prevent future ones. I know we are all human, but I really feel guilty.
My first med error was more of a narc discrepency. My order was to give a pt for Dliaudid 2mg IV. The machine dispensed Dilaudid 4 mg. I entered in the number of vials, but the machine failed and never told me there was an error. My charge nurse caught the error and was really nice about it. My pt actually benefited more from my error, but still. My charge nurse was good about it and we realized that there was something wrong with our machine.
My second error was a woman who had her bladder removed. She was on a Dilaudid Epidural PCA. She was in severe pain, rating it 8/10. She was obese and despite her using her rescue doses, it wasnt helping. No CABS were order for her either. I called the PA on our floor (thats who we go to since most of our docs are in surgery). When my PA called back, I was in the med room and she ordered the pt to get Morphine 5mg. I pulled it out, drew it up and gave the pt her meds. i didnt have my clipboard with me. About two hours later, the fellow saw the pt and realized she was given Morphine. The pt has a documented allergy to Morphine. The PA came and told me. she ordered the pt for some Benadryl and we both explained what had happened to the pt. The pt stated she was in the ER about 10 years ago, had been give Morphine and had gotten dizzy. She was told then she was allergic. The pt did not feel dizzy during my shift at all, in fact she was more comfortable and rated her pain at 4/10. So the PA didnt feel Morphine was a true allergy for the pt. The pt was good about the whole thing, but I apologized profusely.
I know you learn from your mistakes and I truly have. I now write things differently on my cheat sheets for allergies and triple check my meds coming out of the narc machine. However, I still feel very guilty. i dont want my mistakes to kill someone, and that is my biggest fear. Any suggestions???
I made my first med error during my third semester of nursing school and I will always remember it. It seems so silly now but it was a big deal to me then. I didn't cut a 10mg paxil in half before giving it to a pt that was ordered 5mg. Nonetheless....to this day I take my MAR to the bedside and I always check my pt's arm band. Those are 2 things I never waiver on. I am in critical care and the drugs are very different than paxil!
I would try to work in a system that has the best methods for preventing medication errors, CPOE, bar coding and adequate staffing are factors that reduce medication errors.
I to am a new LPN of only a year, working MED SURG and going to RN school. I hate to admit it, but I also have made several med errors. Looking back at the times I made those lerrors, I was very busy with an average of 8 to 10 pts, and my attention being pulled away from my MAR for various reasons by Techs, other nurses, the secretary, etc..
I have learned that when I am reading my MAR, thats my main focus for that exact minute, unless it an emergency. I check the Meds I pull from my med drawer, or the med dispense with my MAR as i pull them, and put a check mark by them. I check them again when i open them to administer, and I tell my patient every med I'm giving them. Most pts know what meds they have been taking, if on long term drug therapy. If they don't know the name, they know what their pills look like. They sometimes question names they havn't heard before. When I have a 10mg tab and need to give 5mg, I write 1/2 on the pill foil/back so when i open it to administer, its a little reminder not to forget to give 1/2. If I have to give 2, I'll write x2 on the pill foil/back.Taking time and a few extras steps, like we had to do in nursing school has helped me greatly.
My hospital also does not have allergy bands on the patient but we do have them noted on the chart. I also found this really weird when I started working here because all through school, the hospitals had allergy bands on patients. I try to make it a habit to ask the patient.
rn-ka1977
7 Posts
I made my first med error during my third semester of nursing school and I will always remember it. It seems so silly now but it was a big deal to me then. I didn't cut a 10mg paxil in half before giving it to a pt that was ordered 5mg. Nonetheless....to this day I take my MAR to the bedside and I always check my pt's arm band. Those are 2 things I never waiver on. I am in critical care and the drugs are very different than paxil!