Suspended for a Medication Error

[Nurse Beth]

The Act

I was a new nurse, and before I had even gotten my feet underneath me, I lost my footing and fell hard.

I made a medication error.

I was fresh off orientation as a brand new nurse on an orthopedic unit in acute care. I rounded with Dr. G on two of his patients... 2 elderly ladies in a semi-private room... the same semi-private room.

Suddenly, Dr. G got my full attention as he barked out an order in my direction "Change that D51/2 NS to D5W on Bed A." (My apologies for referring to patients by their bed assignment, but that's how it happened). At least that's what I thought I heard Dr. G bark... I mean, say.

I was eager to be competent and efficient. So before Dr. G had even returned to the nurses' station, I had the D5W in hand, ran in, took down the bag that was hanging, labeled, spiked and hung the IV. On Bed A... just like he had ordered. An expedient medical intervention by a skilled medical professional, Yours Truly.

I was proud of myself.

I was so wrong.

The Repercussions

My Nurse Manager called me aside later that day.

"I need to see you. In my office.... Now."

The tone in her voice and her words was enough to cause me great concern and anxiety. I had a sick feeling in the pit of my stomach. I followed her into her office unsure what was about to happen to me. She seated herself in her chair behind her desk, and motioned for me to sit across from her. I quickly noticed there was nothing on her gleaming wooden desktop... Except for a single piece of paper. I suddenly felt a sense of doom.

Without further ado, she informed me that I had administered the IV fluid to the wrong patient, which constituted 2 med errors. Apparently, Dr. G's orders read "Change the IV fluid on (Bed B) to D5W."

Uh-oh... So both patients had the wrong IV fluid. I felt faint as the blood drained from my face.

In addition, and most important, I had not identified the patient. She proceeded to inform me that I was on three days suspension without pay, and to clock out immediately. She pushed the disciplinary form across the desktop towards me for my signature.

As busy and short-staffed as the unit was, my mistake was clearly exceedingly profound, as I was being sent home mid-shift and was Banished from Patient Care for three days. I wasn't indispensable after all. Because I was Unsafe. I gathered my things and walked the Walk of Shame with my head down in front of my peers to the elevator. I drove home in the early afternoon on empty streets without traffic. Home to an empty house in the middle of my workday.

How Could This Happen?

We all know the 5 (6, 7, 8 and climbing) Rights of Medication Administration:

• Right Patient
• Right Drug
• Right Dose
• Right Route
• Right Time

So what had happened? How had I failed in something so fundamental? There are many things that contributed to my error. Here are three that I was responsible for:

1. I opted for speed over process and safety.

I took a shortcut by failing to check the written orders, note them, and identify the patient. Following the same process step by step without variance prevents errors. Like an airplane pilot. I learned an invaluable lesson well that day.

BE THE PILOT.

2. Ego. Pride.

I was eager to please and perform. To show everyone, esp. Dr. G, what a bright new RN I was. Because surely Dr. G was going to be impressed by how fast I could make his orders happen. Looking back, I'm pretty sure he was only vaguely aware of my presence at all, and the only thing that might have caught his attention was if I had hung that IV wearing a tutu while whistling Dixie.

3. Unintentional learning- maybe the most interesting.

I had been an LVN before becoming an RN. At the facility where I worked, LVNs did not manage IV fluids. So oftentimes I would be in the room and watch the RNs hanging IV fluids.

I admired their physical grace and coordination while nonchalantly flipping IV bags upside down, backfilling, spiking, reaching to hang....and I so wanted to be one of them! A bona fide RN with IV hanging privileges. But never in those scenarios I witnessed did the RNs ever check armbands for IVs. So the unconscious learning that took place...and that was indelibly imprinted...was that IV fluids are not medications! Crazy, huh? But that learning was exactly what happened...unintentionally.

Of course, in nursing school, there must have been that day where they said "IVs are Medications" Did I miss that day? Was I only studying to the tests, and not the real world? I don't recall. There's school learning and then there's real learning. How real learning takes place is another blog. As I'm an Educator and all.

How I Felt

Shock soon turned to utter devastation. I was on the crazy train. I felt shame, embarrassment. Confusion. I had always been the straight A student. Class President. Honor student. Failure and suspension were not me. I was one of the top RNs in my class. That person. Now, who was I? It was ego-shattering. My self-confidence vanished. Gone. Just like that.

Once home, isolated and alone, my thoughts collided. Were the patients harmed? Would I be fired? Was I forever marked? How could I ever practice nursing again? My emotions reeled. I pictured another RN going into my patients' room and fixing my error. Hanging the right IVs.

Making the mistake was one thing, but being suspended added gravity and shame. This was a felony, not a misdemeanor. I wasn't angry about the harsh punishment. They must be right. I was sick and humiliated. Alone, I curled up and cried, but there was only an hour before my kids would be home from school, and I had to put on my Mom face. Dinner had to be made, homework had to be checked.

Fortunately, the patients did not suffer any ill effects, but that was only luck, right? If I could do what I had done, I could make an even worse mistake, right? I could hurt someone. RNs aren't supposed to hurt people.

Added on was that I was a single Mom of three, and three days without pay was going to hurt. Although I'm sure that was the intent. The rationale being that if the punishment hurt enough, the lesson would be learned.

And finally... I wondered if I should even be an RN. Hadn't I just proved that I shouldn't? Which was confusing, a cognitive dissonance. I had spent 6 years studying to be an RN with unswerving determination and... I shouldn't be an RN?

My world did not make sense.

Recovery

I didn't need suspension. What I needed was counseling and support. Here's what MeNow would say to MeThen:

Quote

"Give yourself time, Beth. Time brings perspective, trust me. You don't know this yet, but every, and I mean every, RN makes mistakes. Welcome to the real world. Reality check- you are not perfect. You also don't know that you are going to be a gifted nurse. And go on to help a lot of people. Figure out what went wrong and learn from your mistake. Find someone safe to talk to. Forgive yourself."

And also from future Me: "Have a glass of wine. You don't know this yet, but a robust Cabernet is going to be your favorite."

I returned to work. From then on, I was obsessed with patient identification. Even if I was in the middle of a med pass, and turned around to grab a unit dose container of Milk of Magnesia out of the patient's drawer, and walked back to the bed...I re-checked the pt's ID. (This was before barcoding).

Time passed, and my shaky self-esteem began to stabilize. Eventually, the good days outweighed that one awful day, and my mistake was finally in the rearview mirror.

Was that my last medication error? Well, as any nurse knows, that's a rhetorical question. No, it wasn't. Making mistakes never got easier, but recovery happened faster. My ego was shattered, but when it came back together, I was more resilient. Healthier.

How did mistakes change you?

How did you recover?

I'd love to hear your feedback.

[Makaiah123]

Thank you!! What an amazing story. We're are not perfect as nurses and as people. We make mistakes. And you do have a gift. Its called being humble and forgiving yourself. And that word resilience was my favorite in lvn school. It means no matter what life throws at you , you get up dus yourself off and you fight!

[Samichaa]

I am foreign grad nurse and waiting to start a career as new RN. I am nervous and excited for new beginning. Your advice means great to me. Thank you for sharing your story.

[klcrn1987]

I am not saying that it is acceptable but let's be honest.... EVERY nurse has made some kind of a med error even if it was a tiny one... we are busy, we are frazzled, we can be distracted, we misunderstand, we are human. Thankfully, 1 wrong dose rarely causes permanent harm.

We learn from our mistakes and go on. Rather than "slam" an error, it should be made an opportunity to teach and learn. If all nurses who made a mistake stopped nursing, there would be very few left!!

[MH1114]

Mistakes do happen. I like how you addressed the 5 rights and why you bypassed them and how to avoid doing it again. Sounds like a good basis for an article.

Another point I would make is that verbal orders are not accepted, to my knowledge, anymore unless you are in an emergency setting. At least this is the policy of our facility. Therefore saying to Dr G. that you would be happy to assist him with that order, once he writes the order. This has saved me multiple times in the Emergency Department (ED) where orders on patients can refer to a different patient, or as you found out you are working on another patient and the patient the doctor was referring to is not the one you thought or was caring for. Also the physician can be the attending or the resident working in the ED for me.

[hewert]

Verbal orders are prone to errors. The trend is to require all med orders to be written by the prescriber with the exception of "urgent" orders. What is your hospital's policy on this? If you were not noncompliant with a written policy, you should not be punished! 'Course the docs find this policy "inconvenient" but it is being successfully used now in many hospitals

[RNShloma]

Sorry to say this, As long as you are a Nurse it will include being Human. Dont let dishonest and self righteous bipolar lying RN or LPNs make you feel like the black sheep of the family. All nurses and I repeat all Nurse make Errors, some who are in management can hide them well and not show how dumb and stupid they really are but there positions allow them to hide there errors and misdeeds. Also you should not have been suspended, a Inservice or Write up would have been ok. These bring you to be more conscious of your errors. I make about 1 to 2 errors a year. So that means i get written up or called into the office about 1 or 2xs a year. First of thats Normal especially since you are human, and Patients lie, Doctors make errors and do not communicate with Nurses as often which is another issue that causes errors and other nurses do not endorse, support or communicate other shifts.. If you are a RN or LPN and you made a mistake trust, me the one writing you up or coming at you made 50 mistakes worse than your azz. And Remember as long as you stay human, you will error, its life and you work with a bunch of other humans, staff, management, and patients Example,,, which i love to give. I came on to a shift i didnt know, so during the medication count i noticed the count was over the number that was in the blister pack, which means Ativan had 27 pills, and the count said 26 pillls and when i looked it said that the pill was given at 8 pm. So i was like this count is wrong , so the outgoing nurse took the pack of 27 disappeared came back with 26 and i didnt say shyt, as long as the count was ok, Now, after this i was preparing my medication cart for the shift and i because i had many patients i put all of my fingerstick tabs in one box along with the glucometer and lancets to make it easier for me.The outgoing nurse was still around and had not left she, had the nerve to tell me how by me pouring my fingerstick tabs in a box that was crosscontamination, and you know wht maybe so but i will pick cross contamination over a finger stick tab than a Narcotic count over the count, which shows your dumb azz didnt even give the medication and documented and was dumb enough to let another nurse see this and we talking Ativan. Then she starts saying how she doesnt want to see that again , I was like well lets go to office and give ourselves in, you to the narcotic and i will confess to cross contamination for putting the fingerstick tabs that i didnt use in a box with the glucometer and the lancets. lets go this dummy and fake Nurse who i feel exist in our profession to numbers that you wouldnt believe didnt say anything, and left me alone and left the unit which was long overdue. by you dumm fake hypocrite who wants to attack others when your own hands are filthy and probably worse than mine. Trust me wrong is wrong but dont try to condemn another when you know we can correct things another way . You shouldnt have been suspended a simple talk to be more careful wouldve done and a inservice. Stop susspending nurses on things you have done far worse but since you a supervisor or related to the DON you got off scot free. Please. thats why keep you business to yourself and handle your own errors your own way. Otherwise you will be left in the hand of a Snake far worse than the error itself.

[AliNajaCat]

Say what again?

[RNShloma]

I forgot to say this, You made a Error and you are a Nurse, Dont worry you are going to make more , just be careful and do your best. Dont let anyone tell you different this is real shyt. If you are human you will Error. Simple and Plain, anyone who tells you different is Lying and a Fugazy.

[PANYNP]

Over the past 15 years I've been involved in teaching Science of Medical Error. There is no need for "naming, blaming, and shaming" in instances of medication or procedural error.

As another poster mentioned, the cause of the error needs to be investigated (root cause analysis), and safeguards activated to prevent recurrence. Causes of these events are multiple - ranging from stretched staffing to unfamiliarity with new devices to malfunctioning equipment to newbie clinicians to power outages etc.

Suspension serves to demoralize a clinician, and while a "lesson may be learned", the cost of the lesson may be loss of an otherwise skilled and valuable employee who has been blamed and shamed to the extent that s/he is unwilling to continue to work in that setting.

[Jmmfan1]

So I am not a nurse but wanted to share this with all of you still. I see how hard the nurses and CNA's work. I am a patient and this is my fourth facility. My second facility I was in I had a nurse come in at 2:30 in the morning, flipped on the lights and said I am here to give you your shot! I said Shot? What kind of shot? He then told me it was my Insulin shot. I said Insulin? I am not Diabetic! He said oh you are not? I said no I am not. He then said I must have the wrong room. I was glad I caught it the first night and the second and third night. After the third night I told the DON (I reminded the nurse the other two times.) I also told the DON I did not get my meds the night before. She talked to him because he came and tried to convince me he had given me my meds. My meds had been counted to which he replied well I know I gave her some meds!! At that point he was put on suspension, the DON was fired and he came back within a day. The Center Director told me I made accusations against his staff. A month later or so he passed away of a overdose. I am not putting blame on him persay how ever there was evidence he was rushing through his med pass. My concern was the possible of insulin shots when I am not diabetic. I had seen this in another facility I was at. When I did HR and Payroll I made sure I had checkpoints in place to ensure my work was correct. Is there anyway of adding checkpoints to med passes as well? And the doctor that barked orders, did you repeat back what he told you? Thank you to all of you for what you do.

[Ruby Vee, BSN]

Nurses are human and no human is perfect. It is a difficult lesson to learn, especially when you are brand new and determined to be perfect. Making the mistake is easy and just takes an instant. Forgiving yourself afterward takes a long time and a lot of work. I'm glad you were able to recover.

[nursegj]

One thing is almost certain (I say ALMOST) is that this will not happen to you again. I have been a nurse for 40 years and I too made an error as a new grad. I swear, my life flashed before my eyes. It was horrible. My Head Nurse was supportive and backed me up but I beat myself up pretty badly. I can say, that in 40 years I never made another med error. That was it for me. I was careful and accountable from that day forward. I followed the procedure: check, recheck and recheck again. I have not let speed or someone "barking" at me make me break protocol.

Don't beat yourself up too much. It happens to almost everybody. Just be careful and follow whatever your med protocol is. Don't be afraid to question orders if they don't make sense. Remember, no matter how the error originates, it is the person actually administering the medication that is most liable if something goes wrong.