Really stupid med error

medsurgrnco, BSN, RN · Apr 26, 2008

I've found that things typically either don't turn out as badly as I feared, or that the consequences aren't as catastrophic as I feared as there are other opportunities/jobs out there.

Crocuta, RN · Apr 26, 2008

I assume that you expect to get called on the carpet on Monday to explain yourself. Common questions asked at these events are:

How did the error happen?

How do you plan to prevent it from happening again?

For the first question, just be honest. If you were hurried and didn't pay attention, say so. If you had a brain fart, say so.

What managers really want to know is the answer to the second question. Spend some time this weekend thinking about your error (but please don't obsess and give yourself an ulcer.) Should you be taking the MAR to the bedside and doing a last check? Can you prepare your meds in a different manner to provide visual cues to remind you of route? Did you do the proper number of checks?

Be honest, remember that you're human and remember that there was not a bad outcome. The patient will live and so will you. :nuke:

*ac* · Apr 26, 2008

Is it common to get terminated for this type of error?

medsurgrnco, BSN, RN · Apr 26, 2008

There'd really be a nursing shortage if they terminated every nurse who made a med error! Suggest you read past threads in this forum about others who have made med errors and have not been terminated. You can just glance at titles to see if they discuss such an issue. One thread had a title something like "...when my common sense went bye, bye..." and talks about a patient who was supposed to be on a heparin drip and several nurses didn't catch it and get the patient on the drip, and no one was terminated.

Ginger45 · Apr 26, 2008

I do not know a nurse out there who has not made a med error. It is very frightening. I made a doozy when I was a new nurse. Luckily it made the pt better and she went home the next day but it could have been fatal. The physician made a joke that I cured her but I did not find it funny. Now, I only take one med at a time (IV). I know that it takes longer but I am terrified of making another mistake and it has been 25 years ago.

rn undisclosed name · Apr 26, 2008

I've made a med error. Gave heparin to someone through their dialysis catheter who was hit+. Did this as a new nurse. Most likely they didn't get very much of it but still. Did the incidence report and notified the physician. All was ok.

A friend of mine gave haldol IV. Was terrified she was going to lose her job. Notified the dr. No harm came of it. She was never talked to about it. She did have to endure some teasing from her co-workers.

We all learn mistakes and move on from them. Take it as a learning experience.

pinkeyICU · Apr 26, 2008

I have made a lot of mistakes....not all of them everyone knows about...but even the small ones make it so I have to swallow VERY hard to get my oral secretions past my heart which stays lodged in my throat for a long time....

The fact is, you will make mistakes. You will continue to make mistakes. The important thing is not to make the SAME mistakes! Well that, and not to kill anyone!

Once another nurse tried to help me out and add more volume to my insulin dripp...she actually increased the rate! Thankfully I went in right after her and the pt only got a few cc's bolus (Dripp off! Accucheck, another accucheck, another accucheck)....But could have KILLED him! I was on my knees thanking GOD I happened to glance at my pump AND happened to catch it (I always put a tape label as to what is infusing thru what pump....Insulin 10ml/hr? What? Wait!!! Was supposed to be 2ml/hr! OMG). At the end of the day, both my pt still alive? Good. I'll go home and sleep it off. Come in next night FRESH and consider myself that much more experienced!

Experienced nurses do not get that way from being perfect all the time.

Ginger45 · Apr 26, 2008

I wanted to add to this because of something that Pinkey said. There are nurses out there who make errors and take it lightly. I was still in nursing school when an RN charge nurse on a med/surg unit scared me half to death. I was supposed to give CA IV to a renal pt. It was 10 am and the med was not due until 2 but I requested her advice because it did not specify how it was to be given on the med sheet just that it was given IV. I had the vials in the drawer but I was working as an LVN on that floor that day. I was cautious of IV meds. Besides that someone had given one of my pts his am insulin then didn't chart it so I gave it again. He stated he hadn't gotten it and was alert and oriented but he had. I spent most of the day doing accuchecks and keeping his blood sugar up. Anyway, she promptly took the vials out, drew them up in a syringe, went into the room and pushed it, fast. I was standing there with my mouth open. I stuttered that it was not due until 2 pm. She then stated, "It's 2 o'clock somewhere." I watched that pt like a hawk and luckily she was ok but I would never work with that nurse again. Not surprisingly after I was an RN, I saw her name in the disciplinary section. I believe that she lost her license. The fact that you are not taking this lightly is all the more reason why we need you!

BlearnRN · Apr 26, 2008

When I was on orientation, I had to give lasix po. Unfortunately, the med was not up from the pharmacy. So, my preceptor told me to give it iv instead and just check off that it was given po. She said that it was not a big deal.---- Basically what I am trying to get at is that at least you did not purposely go the wrong route, some nurses just do it out of convienience or just don't care. I can tell that you care and that it was not just a convienience thing. Just remember that there is a margin of error in this field/ learning curve. It is scarey to think that, but it is the truth. Most negative consequences happen when a patient was harmed. If the pt was not harmed, then that is the end of it.

agr8rn, ASN, RN · Apr 26, 2008

do you see yourself ever making the same mistake again? if not, take it as a lesson learned and move on. if so, get out before you kill someone.*
*i very much suspect it's the former and you're being properly freaked out, but quitting over a mistake where the pt is okay and you learned something doesn't make sense to me. but i haven't been in your shoes yet. but i think you should stay.

i think you should take the advice of all the other nurses on this board, but try to ignore the negative of this. as new nurses, and old nurses, we are human and make mistakes.

to ask someone if they see themself making the same mistake again is senseless; no one can predict what will happen in the future that will cause or contribute to us making an error...

however, i do believe that once we make an error that is significant and affects us deeply, we will certainly remember it forever, and are less likely to repeat it.

keep your chin up, admit what you did, be remorseful and speak with your supervisor about what you think may have contributed to the error. there is no excuse for making an error, but there can be contributing factors such as being understaffed, heavy patient load, etc, etc...

you also might want to consider a pharm review course maybe. shows initiative and being proactive.

good luck and keep us posted.

amanda

[email protected]

BlearnRN · Apr 27, 2008

------By the way - I told my preceptor that I did not feel comfortable giving it IV and that I was just going to wait for the po.------

TiredMD · Apr 27, 2008

There was a student a few years ago (don't actually know the student but have heard stories from instructors) that pushed some PO liquid tyelnol into the childs IV and killed him. Scary to think about.

I wonder if that's just scare tactics from the instructors. Liquid Tylenol is just acetaminophen, sugar, and water. Unless there are colorings or preservatives that are toxic IV (but not PO), all of those components are safe IV. Did they offer you an explanation on why this supposedly killed the kid?