1st Med error... and a valuable lesson!

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Specializes in Hospice, Med/Surg, ICU, ER.

I learned a valuable lesson yesterday. :eek:

I am a (starting) 3rd Quarter LPN student, and I work as a CMA in an Urgent Care clinic. In my facility, LPNs and CMAs are interchangeable: we have the same duties and responsibilities, all under the auspices of the MD inhouse. As is my basic nature, I am VERY careful when it comes to med administration - I'm the type that will do 3 or 4 verifications on a med before I pass it. If this had been a "serious" med, I don't think I would have made the mistake; however, because it was an OTC, I got in a hurrry and got careless; and it came back to bite me on the assets!

Yesterday, I had a family come in (3 little ones and both parents) all pos for strep A. Initially, only two were my pts - the older two children. After screening, I discovered the middle child had a temp, while the eldest was afebrile. Per facility protocol, I administered (correctly) the correct dose by weight of APAP liquid to that child. As I was finishing, Mom asked if I thought the youngest (2 y/o) had a fever; upon checking axillary temp and seeing 102.2, I said "Yup, she's got it too. Let me get her some tylenol as well." So.... I went to the med cabinet and poured the correct dose for her weight, and went back in and administered it. No problem. Later, when the MD made it into the room, he checked all three of the kids, then came out and had me strep-swab the two parents as well. EOS, the whole family was treated for strep, and off they went.

A short time later, the other CMA on duty came up to me and asked "Are you SURE that was APAP you gave that last time?" Of course I was sure! Until she led me to the cabinet and I saw that the children's APAP suspention bottle that I used on the first kid's dose was pushed BEHIND the bottle of children's benedryl! I honestly COULD NOT remember whether I had given the little one APAP or diphenhydramine! Both bottles LOOK the same, as does the med within! Oh.... SHIZZLE! A panicked check of the chart and a quick calculater session revealed that I administered 8.25mg of diphenhydramine to a 28lb 2 y/o. Not enough to hurt her, THANK GOD!!!!

The LPN on duty told me I had to tell the MD, which I did. He told me I needed to advise the pts parents, have them recheck the temp, and if still elevated (which it would be) to administer the correct dosage of APAP to the little one. Done, and the parents understood - again thank God. The MD also said that if this was the only med error I ever made in my career, I should be greatful that is was one without serious consequences. Boy howdy, am I!

The moral of the story: Always verify the med pulled EVERY TIME! Even if you just gave the same med two minutes before, even if you THINK you know what you are getting. The "5 Rights" are there for a reason. I am sooo greatful that I learned this lesson before I seriously hurt someone.

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Our policy (with pediatrics) is to have a second nurse verify the medication and the dosage. It can be a life saver.

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Specializes in Almost everywhere.

This is a very valuable lesson and one I'm sure you will remember for a long time therefore you will exercise more caution. I don't know of any med to be totally benign however. I am referring to your comment that you may have not made the mistake if this were a more "serious" med. Meds are not foolproof no matter how benign they seem. Thank you for sharing your experience...makes one think.

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Specializes in Almost everywhere.
Our policy (with pediatrics) is to have a second nurse verify the medication and the dosage. It can be a life saver.

:yeahthat: Good point with regards to any pt esp. kids!

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Specializes in Hospice, Med/Surg, ICU, ER.
Our policy (with pediatrics) is to have a second nurse verify the medication and the dosage. It can be a life saver.

Sounds like a good policy to me.

However, in my case, the dosage WAS correct; just the med itself was incorrect.... and the meds look identical in the dosing cup. I don't know if verification would have caught this one, unless someone else had verified the supply bottle.

I can state this with absolute authority...... this won't happen to me again! ;) My normal caution has been raised to absolute paranoia.

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yeahthat.gif Good point with regards to any pt esp. kids
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Specializes in Hospice, Med/Surg, ICU, ER.
I am referring to your comment that you may have not made the mistake if this were a more "serious" med. Meds are not foolproof no matter how benign they seem.

I agree.

My point was that because it was an OTC, (and we were absolutely SWAMPED yesterday) so I just snatched the bottle, calculated the dose, and drove on...... OOPS! With anything else, (and I gave more IM stadol and phenegren yesterday than I thought was manufactured in a year) I am so cautious that I routinly take a ribbing from the rest of the staff: "Will you verify this for me? Are you SURE the MD wrote 2/25, I can't hardly read it.... You get the picture.

In my head, I said APAP - no biggie. What a way to learn that so much of what I "know" just ain't so. :rolleyes:

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Specializes in Almost everywhere.
Sounds like a good policy to me.

However, in my case, the dosage WAS correct; just the med itself was incorrect.... and the meds look identical in the dosing cup. I don't know if verification would have caught this one, unless someone else had verified the supply bottle.

I can state this with absolute authority...... this won't happen to me again! ;) My normal caution has been raised to absolute paranoia.

Um, yah...I have the habit of having another nurse check the supply where I got the med, the package it came out of, the bottle I poured it from, etc...this has saved me much trouble over all of these years. Course, my workmates may get sick of me, but I would gladly do it for them, and I do. ;) Another pair of eyes is usually helpful.

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Good lesson but where are you that you still have stock medication? We have a pixis system where every thing is single dosing pretty much. Medications like Tylenol although it are not single dose it is in a single drawer so you cannot accidently give benedryl. Benedryl is however single dose in our facility.

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That is a valuable lesson and thank you for sharing. We can all learn from our mistakes and others.

Here is my big mistake......thank heavens no adverse effects. I had to hang a Theophyline drip. I got the drip from Pharmacy marked "Theophyline"...only problem it was Heparin instead. The MD caught it almost immediately after I hung it. Moral of this story... pharmacy are humans also...double and triple check.

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Specializes in Day Surgery/Infusion/ED.
Sounds like a good policy to me.

However, in my case, the dosage WAS correct; just the med itself was incorrect.... and the meds look identical in the dosing cup. I don't know if verification would have caught this one, unless someone else had verified the supply bottle.

I can state this with absolute authority...... this won't happen to me again! ;) My normal caution has been raised to absolute paranoia.

If you think you will never make a med error again, you are wrong.

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Specializes in Almost everywhere.
That is a valuable lesson and thank you for sharing. We can all learn from our mistakes and others.

Here is my big mistake......thank heavens no adverse effects. I had to hang a Theophyline drip. I got the drip from Pharmacy marked "Theophyline"...only problem it was Heparin instead. The MD caught it almost immediately after I hung it. Moral of this story... pharmacy are humans also...double and triple check.

Hoooo Yah! :yeahthat: Thanks for sharing.

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