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Discussion

Stupid Med Error

I work in the NICU.

My patient had a PIV running TPN and lipids. They had tried to put a UVC in the patient but was not able to. Coming on to my shift, they had finished giving antibiotics. I basically ended up confusing the protocol for flushing a double lumen UVC with a PIV. Later in my shift I realized there was no medication going through the medication line. So I went ahead and ordered 2unit heparin flush q4 and administered it.

I didn't realize what I had done until I was giving report and I discontinued the heparin flush immediately.

I assessed the IV site with the day shift nurse and it looked okay. I also filled out an incident report since it is a med that was not needed to be given.

I am almost at my 1 year mark as an RN, and I just felt so incredibly stupid and upset that I did not realize this sooner. Theres that sinking feeling in my chest that I just can't get rid of. Of course with a continuous line, you don't need the heparin flush! I for sure will never be making this same mistake again. but does anyone have any advice for me? Or have experienced a similar situation?

  • Quote

    • Featured Replies

    1. Everyone makes mistakes.

    2. No harm came to the patient

    3. You learned something in the process

    Deep breath........it's ok

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    • Experts

    My first medication mistake involved incompatible IV solutions and a central line...in nursing school no less. The patient was OK. I was OK at the time too. The gravity of it didn't hit until I got home. The worst part was having to address it with my instructor the next day: I don't know if my preceptor ever told her, but I figured that my instructor should probably hear it from me first. It was the only time I ever cried during nursing school.

    As meanmaryjean said, no harm came to the patient so you are very lucky--consider it a learning experience. Finish beating yourself up tonight, then forgive yourself and move on. If management does address it with you, don't try to cast blame elsewhere: admit where you went wrong, what you've learned, and what you're going to do to ensure that it doesn't happen again.

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    How is it that you ordered it?

  • Quote
    1. Everyone makes mistakes.

    2. No harm came to the patient

    3. You learned something in the process

    Deep breath........it's ok

    As long as you learn from this, it will be ok. Advise is to learn from this and move on.I am not trying to downplay a med error and I am glad no harm came to the patient. But meanmaryjean is right, take a deep breath...it will be ok.

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