3 medication errors in 7 months!

Nurses New Nurse

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I know, I know...most of you must be looking at this and thinking :eek: I'm living it and I feel the same way. I'm posting this because I really need some advice; I'm depressed, confused, feeling incredibly stupid and very guilty. Let me give you the scenarios and you can tell me what you all think. By the way, in case you can't tell...I'm a new grad, June 2005:

1) First medication error occured when I gave the wrong patient the wrong medication (I did a stupid thing by carrying two patients meds at the same time). This patient happened to be a chronic pain patient, knew the medication wasn't for him but accepted the medication anyway. The medication was Percocet 5/325. I alerted my charge nurse right away, told the doctor (who started laughing and told me not to worry about it because this patient was on so many meds the percocet wouldn't do anything to him.), and wrote out the incident report. Went home that day feeling terrible and wondering if I'm really going to be good at this. :o

2) Second error: received report from Step-down unit, was told this patient had not received his evening dose of Coumadin. When this patient came up to the floor I looked in his file to see if the Coumadin had been given, couldn't find the documentation in the usual place, called the nurse back in an attempt to find out whether it had been given or not, later found out I was connected to another nurse who had also given me report that same night and who told me she had not given the Coumadin. Gave the patient 5mg Coumadin and then found out the original nurse had already given the 5mg!!! Once again filled the incident report and once again went home feeling terrible and wondering if I made the right decision to be a nurse. :o

3) Latest one: Received report from one of the nurse on my floor that the patients Unasym had been discontinued and the patient now had an order for Penicillin Q24hr, when I looked in the MAR I saw the registrar had picked up the order as Q24hr also, I signed off in the patients chart right under the registrars signature. To make a long story short, next day received a call from the charge nurse on days alerting me to the fact that the patient had missed 3 doses of her penicillin because it was ordered for Q4h!! Filled out another incident report, was written up for this latest occurence, went home and cried myself to sleep and have been feeling horrible ever since. :o :o

For the past 20 years all I've wanted and dreamed about was becoming a registered nurse, I graduated at the very top of my class, received the Gold medal at graduation, and am was hired at one of the top orthopedic facilities (which has Magnet status) in the nation right out of school. I can't help but wonder...what has gone wrong? :uhoh3: I can honestly say, I've learned from each and every incident, but I'm beginning to wonder if I should quit before I'm fired. :crying2:

Any and all advice will be very much appreciated. Thanks.

I am a reg. nurse's aide at a an asisted living home for dd adults. The invironment is disruptive to say the least and at times distractions happen at med times. I have made a mistake about once a month since staring this job, almost every month. And I have terrible anxiety about it. once in awhile I miss a med like in the afternoon or something. Then I also once or twice have given an extra dose of primidone for example, by mistake. Sometimes I have thought the bubble pack was dated for today when it was tomorrows dose, and convinced myself that I need to still give the dose even though I was sure I already had. Should I quit now and go live in the homeless shelter?

NYC stop beating yourself up. Med errors suck, there is nothing like the feeling you get when you realize you made a med error or think you might have made one. As others have said most med errors are the result of system failures not personal ones. I have worked with wonderful nurses who have made far more devastating (including fatal) errors that while tragic and not something to take lightly were not career ending. I am willing to bet that most nurses have made med errors in their careers, some are unaware of them and sadly some are unwilling to admit them when they are aware. Learn from it, forgive yourself and allow the mistakes you have made to make you a better nurse not discourage you from your lifelong dream.

Specializes in Geriatrics.

You back then are me right now....I've been a nurse for a month...made 2 med-errors...I work 3rd shift and am constantly "encouraged" to "hurry up"...The pressure to hurry...it's getting to me. I was called in the office today to see how they could help me stop working overtime...staying too late charting. It's not worth it!

Specializes in ER.
I know, I know...most of you must be looking at this and thinking :eek: I'm living it and I feel the same way. I'm posting this because I really need some advice; I'm depressed, confused, feeling incredibly stupid and very guilty. Let me give you the scenarios and you can tell me what you all think. By the way, in case you can't tell...I'm a new grad, June 2005:

1) First medication error occured when I gave the wrong patient the wrong medication (I did a stupid thing by carrying two patients meds at the same time). This patient happened to be a chronic pain patient, knew the medication wasn't for him but accepted the medication anyway. The medication was Percocet 5/325. I alerted my charge nurse right away, told the doctor (who started laughing and told me not to worry about it because this patient was on so many meds the percocet wouldn't do anything to him.), and wrote out the incident report. Went home that day feeling terrible and wondering if I'm really going to be good at this. :o

2) Second error: received report from Step-down unit, was told this patient had not received his evening dose of Coumadin. When this patient came up to the floor I looked in his file to see if the Coumadin had been given, couldn't find the documentation in the usual place, called the nurse back in an attempt to find out whether it had been given or not, later found out I was connected to another nurse who had also given me report that same night and who told me she had not given the Coumadin. Gave the patient 5mg Coumadin and then found out the original nurse had already given the 5mg!!! Once again filled the incident report and once again went home feeling terrible and wondering if I made the right decision to be a nurse. :o

3) Latest one: Received report from one of the nurse on my floor that the patients Unasym had been discontinued and the patient now had an order for Penicillin Q24hr, when I looked in the MAR I saw the registrar had picked up the order as Q24hr also, I signed off in the patients chart right under the registrars signature. To make a long story short, next day received a call from the charge nurse on days alerting me to the fact that the patient had missed 3 doses of her penicillin because it was ordered for Q4h!! Filled out another incident report, was written up for this latest occurence, went home and cried myself to sleep and have been feeling horrible ever since. :o :o

For the past 20 years all I've wanted and dreamed about was becoming a registered nurse, I graduated at the very top of my class, received the Gold medal at graduation, and am was hired at one of the top orthopedic facilities (which has Magnet status) in the nation right out of school. I can't help but wonder...what has gone wrong? :uhoh3: I can honestly say, I've learned from each and every incident, but I'm beginning to wonder if I should quit before I'm fired. :crying2:

Any and all advice will be very much appreciated. Thanks.

as for the Coumadin dose, did that nurse that gave it (prior to you) chart it? What about looking it up in the Pyxus (if you all have that) to check, not taking a person's word. I never trust anyone, that's just a CYA thing. If you can't find it and you are not sure, call the pharmacy to double check if it was dispensed BEFORE you give it. But it sounds like anyone could have made that mistake.

As for the mixup with the PCN, appears to be a transcription error initially... no? I'm not familiar with PCN q 4hr.... was this PO? I'm used to IV antibiotics... and I don't work on the floor, but q4 seems a bit frequent to me...

Don't carry meds on more than one person at a time... bad idea and just totally adds to confusion.

Give yourself a break - have another nurse double check your meds with you before you dispense, if you're at all distrusting yourself. A good nurse doesn't mind double checking... takes two seconds.

Specializes in Geriatrics.
I am a reg. nurse's aide at a an asisted living home for dd adults. The invironment is disruptive to say the least and at times distractions happen at med times. I have made a mistake about once a month since staring this job, almost every month. And I have terrible anxiety about it. once in awhile I miss a med like in the afternoon or something. Then I also once or twice have given an extra dose of primidone for example, by mistake. Sometimes I have thought the bubble pack was dated for today when it was tomorrows dose, and convinced myself that I need to still give the dose even though I was sure I already had. Should I quit now and go live in the homeless shelter?

I guess I'm not alone in this! lol Hold tight...

I made one today and I've cried so much I can't hardly see to type this. Patient is ok but I can't even express how stupid I feel. I let the pressure to hurry up get to me and got careless. Clerical told me patient was in for shot, I checked for a current Rx but didn't even pay attention to date of last shot on MAR (I know, stupid) and gave shot too early. I'm new and was too trusting of clerical. I know what I have to do now but it was so humiliating to call the Dr. after he had complimented me earlier in the day on what a fine job I was doing. I hate myself right now.:banghead:

Specializes in Geriatrics.
I made one today and I've cried so much I can't hardly see to type this. Patient is ok but I can't even express how stupid I feel. I let the pressure to hurry up get to me and got careless. Clerical told me patient was in for shot, I checked for a current Rx but didn't even pay attention to date of last shot on MAR (I know, stupid) and gave shot too early. I'm new and was too trusting of clerical. I know what I have to do now but it was so humiliating to call the Dr. after he had complimented me earlier in the day on what a fine job I was doing. I hate myself right now.:banghead:

Okay...now I'm about to cry... You poor thing! I'm not alone, but part of me wishes I were so you wouldn't have to deal with this!

Specializes in Gyn Onc, OB, L&D, HH/Hospice/Palliative.
Well it seems like #2 wasnt your fault. And you probably could have gotten a one time order from the doctor for the first one to cover yourself. Number 3 I'm not sure about. Seems like a transcription error.
:yeahthat: :redpinkhe
I had a charge nurse come in and made a med error on one of my patients right at the start of the shift, personally, I think alot of med errors aren't reported.

JMO.

But you'll do fine. Good luck

I will attest that! Many times it is easy not to report (not judging - just stating fact). You are not alone.

Reading all these responses, I wonder, do the facility you work for offer any type of "nurse support system" to help. I can understand being written up to serve as a reminder, but this is one reason most of us choose to leave nursing...lack of support. Do you have a group you can discuss you guilt and fear with? :crying2:If they do, what is the support group called.

Specializes in CRNA.

I think it is great that you are taking personal accountability for your own mistakes. This is the first step in solving any problem. The culture of blaming others does not solve problems, it only prolongs them. Pharmacies, missing MARS, illegible practitioner handwriting and even other coworkers can make your job more difficult at times. However, the nurse is the one giving the medication and therefore, the nurse is responsible for insuring that the patient is being taken care of. You should know that every nurse on this board who has worked long enough has been responsible for a medication error. Try to slow down your pace. If you have to, review the 5 rights before pushing anything through that pimpdaddy 14 gauge. Also, maybe reviewing a medication error CEU might be helpful as well.

http://www.medscape.com/viewarticle/550273

http://www.newfoundations.com/Policy/Pietsch.html

I'm a new LVN grad myself working at a LTC for 5 months now. I have been floating since the begining but its only a 99 bed facility. I think I have done well learning everyones morning, noon, evening and noc meds but the other day I got suspended for 3 days for my first med error. I didnt administer coumadin to a resident because I could not find it anywhere in the cart. I made the awful mistake of not getting it from the ekit as well. Stupid I know. I dont know why that didnt cross my mind. I had noticed however that 3 different nurses had been signing for this med so I asked the same person who worked that cart the night before who happened to be working that evening on another cart where the medicine was. Least to say after a phone call to the pharmacy the med was never ordered. The others were signing but not giving is my conclusion. The don said they got it from the ekit but why did they not document that on the mar or order the med in the first place after realizing it wasnt there. why would they just keep getting it from the ekit? was the pharmacy out of supply?? and why didnt the other nurse tell me he got it from the ekit??? So I was the only one getting suspended for this...I think its totally unfair. :confused:

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