Suffering through a medication error

[KC2010k]

Im suppose to be an experienced nurse and I should know better! I know my seven rights and three checks I teach them to students, but I have made the same med error twice in the past three months. I replay it back in my mind and ask myself, "how the &$@@ did you do this...again!" I played the first med error off as "you are damn lucky because that had the potential to be seriously harmful to your patient. Smarten up! Pay attention! Don't make that mistake again!" BUT I DID IT AGAIN! This is my mistake....

The first time:

I had a scbf primed with morphine 10mg/ml. The order was for morphine 5mg. I pushed hydromorphone (10mg/ml) and gave .5ml. I was lucky that someone picked up on my mistake before more morphine was pushed through the line then giving the patient a hydromorphone dose instead!!!

I have now repeated this mistake but it was a hydromorphone line and I pushed morphine...

I have been so fortunate that no harm came to either patient because I would never be able to live with myself....

I'm typing this questioning my ability to be a nurse....I feel so incompetent. It was bad enough that I made this mistake once but twice! My co-worker tells me that is good that I suffer from my mistakes because it will make me a better nurse in the end...but I have to question this because why would I make this mistake again! These are high risk medications and serious harm could have occur to my patients....I can't have that happen.

I'm trying to develop a plan my action for myself to remember to slow down and remember my checks....suggestions are more than welcome! I want to be a good, safe nurse in the future and this mistake can NEVER happen again!

[EmmaZ06]

It seems like your facility may need to review it's med administratin policy. My guess is that if a seasoned nurse did it twice, it has happened to other nurses as well, who may have been too afraid to speak up about their mistake.