Former PICU nurse here. Agree with your points. However, where I have worked in the past, we always took an emergency med kit with us when we transported a patient to a different department for procedures. I get that with Pyxis systems, you can't just pull out meds and leave them in a kit. But kits can be made and stocked in the Pyxis. This is safer, requiring a second nurse witness, and more convenient for other situations when these meds are needed for a rapid intubation etc...
Maybe I haven't thought through all the consequences of having kits, but it seems like a safer practice all around.
As far as this situation in general, most of what I believe has already been said. Rushing and being pressured can cause even a knowledgeable nurse to make errors. I cannot stress enough how horrible it is that for a role as important as ours (Nurses...especially critical care), should ever be rushed and pressured with all we juggle.
Nurses cut corners all the time in order to get things done expediently. This is WRONG WRONG WRONG, but I've done it myself at times and understand the urgency one feels when in this position which is more the norm now than the exception.
Our knowledge base, capabilities, and responsibility has grown tremendously over the years. Yet, we staff as we did 20 plus years ago when there was less to know and do. Less procedures, less medications to know, less treatments and equipment for just about anything I can think of.
There most certainly were errors in this tragic situation at just about every turn, but as far as errors in general, there would be less, no doubt, if we took out rushing and pressure from the equation. When a Resource Nurse is rushing around from task to task, you know the ones with assignments are doing the same. There is just too much to do all around.
Having quit a caustic environment as a brand new RN nearly 30 years ago, I was instructed to apply for unemployment benefits in order to utilize the Illinois Department of Employment Security (IDES)'s job finding service.
I told them, "I'm an RN. I shouldn't have much trouble finding a job. I just want to use the job finding service. Besides, I quit my last job. I don't think I'll be qualified for benefits".
Still, I was told that I needed to apply for unemployment benefits in order to use the job finding service, so that's what I did.
Lo and behold, IDES ruled the working conditions were unfair, I had followed the correct guidelines before quitting, and was awarded benefits.
Perhaps you could do the same, MotoRN.
As far as seeking retribution in reporting them, I adhere to a concept that was introduced to me by Mr. Edgar Cayce: "You can't get someone into more trouble than they can get themselves into".
Good luck and the best to you, MotoRN!
Glad your patient was ok and be glad that this error was not fatal. We have all been there. Looking into most mistakes, a lot of the time it's not just the nurse, but the environment that leads to medication errors. Systems in place in that unit, constant interruptions from drs and family members, the list goes on.
Is it possible to change to preparing each patient's medication in front of them and not everyone's all at once. To me this is just an error waiting to happen. I'm sure you're not the first nurse in tgat situation to make a mistake, but honest enough to admit it.
The worst mistake I made when I started nursing was not checking blood results before giving out meds. Patient was in renal failure and gave them potassium. Felt terrible and they had to get dialysed they ended up ok, but was mortified. It's made me a better nurse as I check absolutely everything before giving meds etc.
Obviously very upsetting, but at the end of the day, if the patient didn't die or suffer permanent disability, it's just unfortunate vs. life altering. Be relieved and learn from it (as I'm sure you have).
And I agree with Dy-no-mite Nurse1, distractions and constant bare bones understaffing are really a problem as far as med errors are concerned. Rush, rush, rush, pulled in a thousand directions. Patients First in 2019 means minimal RN staff, no secretary, no transport, and one tech for a whole unit. Any complaints and we are told to huddle and work as a team. 😡
You didn't try to hide it, you followed up, and did your best to monitor/stabilize your patient before he was sent to ER. Sounds like pre pouring meds is common practice at your place like most psych facilities. Don't be hard on yourself and I'm certain you won't let it happen again.
So what did you learn from this?
What changes in your practise will you make to prevent this from happening again? That is what you should take from this.
Everyone makes mistakes. That is why the eraser, white out and the back button all exist.
Of course you’re shaken up - it’s because you’re a *good* nurse.
We’ve all made med errors. Those that haven’t, will. We just need to learn from them.
This is a *facility wide* learning experience. Not just you. Never pre-pour, always scan, always always always the 5/7 medication administration rights. In psych some floors tend to get away from this ... our child/adolescent floors do this and it boggles my mind because it’s an accident just waiting to happen (as you found out). On the Geri psych floor we have the WoWs, we pull one at a time from the Pyxis, we scan etc etc.
The facility needs to own up as well.
You're going to be ok.
We've all made mistakes. Every single one of us. Anyone who claims they haven't is either lying or too stupid to realize they've made a mistake. I'd rather have the nurse who recognizes their mistake, admits it, and then does her best to take care of the patient. I'd rather work next to them, and I'd rather have them taking care of me.
I once told the wrong family that their loved one had died. Seriously. I was charge in the CCU, and we were told we were getting two patients from the ED. One was named Johnson Thomas and the other was named Thomas Johnson. (I kid you not -- those weren't the two names in question, but they were just like that.).
We got the bed ready and we waited . . . and then we heard a code called in the ER. In due course, I got a call that Johnson Thomas had gone to the Cath Lab and Thomas Johnson had died. But the family was already on the way up to the CCU to look for Thomas Johnson, so could I please let them know because they were too slammed to go looking for them.
Mr. Thomas came from the Cath Lab with the cardiologist, a couple of residents, a procedure nurse bagging and a respiratory therapist pushing a ventilator. We got him all settled in and I went to get his family to come in and see him. While I was in the waiting room, Mr. Johnson's family wanted to know when they could see THEIR loved one. I told them he was still in the ER, and they needed to go back to ER . . . but they'd been back and forth from the ER to the Cath Lab to the CCU waiting room, and they were upset, and the resident and I ended up telling them as gently as possible that he had died. Right about then, Mr. Thomas's family came out of the CCU upset because that wasn't THEIR loved one in the bed . . . .
Our hospital didn't have a name alert policy at that time. They did the next day.
Everyone makes mistakes. What matters isn't that you're perfect because that just isn't possible. What matters is that you do your best for the patient. Sounds like you did that.
I think stick it out. 6 mos goes by quickly and if that ensures a better employee record for you, then I would try to stay until then.
I don't know the specialty you are in and also, easier said then done, but....
Unless someone is critical or tilting on the edge of critical, just try to slow down as far as feeling pressure and do your best. Just try to work your priorities and flow with your work. If everything is not done, then so be it. The fact that we nurses run like crazy and manage somehow to get the work done, allows the managers to get away with short-staffing.
Just some thoughts without knowing the details of your work...Good luck!