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.

Thank you for the advice all. I spoke with my DON today and things changing for the better. Thank you again.

Yes, in the US. The order was not in the computer yet, so that is the first place it went wrong. The nurses do it all the time at my facility and I started to do the same... Also, meds can't be barcode scanned in the ER because the aren't verified by pharmacy yet. So, I hung the med, with the incorrect rate and checked it off the MAR after it had been infused. All bad. I will be meeting with my DON to discuss all of this, and hopefully make changes for the better.

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?