Risperdal for coumadin!


I am absolutely mortified. I have been a nurse for 9 months. I work on a skilled nursing unit and tonight I gave a patient 1MG Risperdal instead of coumadin. I've had to take the coumadin out of our back-up supply for the last three nights. Our back up meds are a stack of trays with different compartments for all of the meds. Well, I had gotten complacent. I grabbed the wrong tray and took four pills out of the compartment I thought contained coumadin. Similar size, shape, color. While I was giving them to the patient I thought, "wow, I didn't even check the label on these this time" so I stopped and looked in the trash and saw "risperidone" on the back of the bubble pack. I felt like I was going to faint! I automatically told my supervisor, called the patient's wife, and called the on-call physician who (rightfully!) gave me an earful.

I am horrified at myself. What a stupid thing to do! What kills me is that there is absolutely no excuse.. the entire blame is on my laziness and complacency. The tiny silver lining is that I will NEVER EVER give a drug without reading the label again, even if I have given it 5, 10, 100 times and the med looks correct. I wish that my supervisor had yelled at me, I feel like I need to get flogged I feel so bad for the pt. (No ill effects thank goodness, but it doesn't even matter.)

I don't want a pity party, I just had to get this off my chest. I am not a stupid person, and that was a stupid thing to do. I have to really examine myself and think about why I did it.


77 Posts

Specializes in Emergency, LTC. Has 1 years experience.

I just want to say, THANK YOU! We all make med errors and it really shows how good of a nurse you are and your integrity by owning up to your mistake. I can guarantee you that your supervisor has actually gained MORE trust in you from this experience!

It's a horrible feeling making a mistake but you handled it the best possible way you could and thank goodness there were no ill-effects from it.

Thank you for sharing!



106 Posts

Has 6 years experience.

Med errors happen. No one is perfect. Learn from this and move on. You are doing fine.