1st Med Error

Editorial Team / Admin · Sep 15, 2015

First of all, learn from this experience. Now that you've made an error (and we've all made them; anyone who says they didn't either hasn't been a nurse for very long, is lying, or never realized the error), what can you do in the future to prevent another? That should be the key takeaway from the event.

The one thing I would caution you on is assuming. Just because the physician never called back doesn't necessarily mean that he/she doesn't think it's a big deal or that he/she actually received the page. If you don't receive a response after a few pages, take it up the chain of command. Actually speaking with the physician means making sure he/she is aware and covering your gluteus maximus.

AJJKRN · Sep 15, 2015

Besides following the 5 (or 6 or 7 now) rights for medication administration, develop a system and stick to it. Just like doing a head to toe the same way for the most part on each Pt, if you apply the same concept to your med administration you will find consistency helps to prevent errors.

Why did you give more than the recommended dose? Did you forget to cut a pill in half, etc. would scanning that med last (or whatever you do to chart giving it) and using a pill cutter to cut it in half before you get distracted help?

I also over the years have found that if I have multiple meds to give via multiple routes then I scan the meds in clusters by route (scan PO then give the PO, scan subq then give the subq, scan IVP then give the IVP). Helps me to give all of the meds via the corect route.

Bottom line, develop a system that works for you and follow it for Pt safety. Mistakes happen even with being a prudent professional, learn from them with humility and respect the safeguards put in place to help maintain medication administration safety.

It is a big deal, regardless of whether on not it harmed a Pt or not, but we are human and we are always learning. Become comfortable in your abilitities but don't let your guard down. Our Pt's depend on us and they trust us to keep them safe to the best of our abilities.

OUxPhys, BSN, RN · Sep 15, 2015

The pt was my last med pass for the morning and the only new pt I didnt have the day before. It also was a busy day on the floor because of call-offs, shortages in staffing, and my coach being given charge nurse duties even though we were only there for 8 hours that day (charge is never given to someone who is there with 8 hours and usually not to someone with an orient).

I've had time to think about how I pass meds and what I can do from here on out to prevent future med errors. This has definitely been a learning moment that I will not forget.

meanmaryjean, DNP, RN · Sep 16, 2015

The pt was my last med pass for the morning and the only new pt I didnt have the day before. It also was a busy day on the floor because of call-offs, shortages in staffing, and my coach being given charge nurse duties even though we were only there for 8 hours that day (charge is never given to someone who is there with 8 hours and usually not to someone with an orient).
I've had time to think about how I pass meds and what I can do from here on out to prevent future med errors. This has definitely been a learning moment that I will not forget.

NOT to pile on, but you still have not identified how/ why the error was made. You listed a bunch of contributing factors, but none of the things you listed caused the patient to get twice as much drug as prescribed. What caused you to give this patient an incorrect dose?

OUxPhys, BSN, RN · Sep 16, 2015

Thinking back it was because I scanned my meds and when the alert came up I clicked partial dose and I put in the partial dose but then I never split the pill.

allnurses Guide · Sep 16, 2015

Thinking back it was because I scanned my meds and when the alert came up I clicked partial dose and I put in the partial dose but then I never split the pill.

Well, here's what I do when I have a partial dose:

1) As soon as I pull the med, I write on the package, "1/2" so I remind myself, as I open the package later, not to forget to cut it.

2) As soon as I scan a partial dose, I stop and cut that puppy in 1/2 so I don't forget.

3) I try to leave partial doses for the end of my pill scanning. Just my preference, but it's just more efficient then scanning, stopping to input a "partial package" and the dose, cutting the pill and then scanning whole meds again. It's just more organized that way and better organization lessens mistakes.

4) Keep your scanned whole meds and your partial doses separated from each other on your work space.

Hope some of these tips help.

:)

rnforforty · Sep 17, 2015

The nurse who claims never to have made a med error must not do anything! So said one of my instructors better than 40 years ago.

There are the errors you know about and then there are the 'insensible' ones - those that neither you or anyone else catch. Like when the patient has just finished swallowing a whole cup full of pills and says 'Gee, I never had the pink one before'. And the garbage bag that you tossed the blister packs in left the room via housekeeping 10 minutes ago! Happy garbage hunting!