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Terrible Medication Error

Posted
rekea526 rekea526 (New) New

I made the worst medication error today and feel so horrible about it. I literally wanted to quit the job from sadness and embarrassment. I'm a new nurse and have only been working at the hospital for about 5 months. I've been a nurse for about 10 months.

I had a patient on a Lasix drip that was 100ml total volume. 100 mg in 90ml which calculated out to be given 5ml/hr. This may sound confusing but long story short I infused the medication at 100ml/hr instead of 5ml/hr because I was looking at the 100mg in 90ml and I was also looking at the 100 ml total volume instead of paying attention to the 5ml/hr like I should have. I and the charge nurse caught the error but 75ml had already gone in a little over 3 hrs when this medication should have lasted for almost 20 hrs if it was done correctly.

We contacted the doctor he said to just monitor him, I filled out an incident report, and we restarted the infusion at the correct dose. I believe I got confused because of all the different numbers on the IV bag and I was also very busy that night. The result of this was critical potassium of 2.1!! we luckily had a potassium protocol to start potassium IV 50ml/hr for 6 bags total and recheck the level. I felt humiliated!! and so embarrassed.

I knew everyone had known my mistake because a random nurse came to me and asked me if I was ok. I knew he was asking this because the charge nurse must've told him what happened. I feel so dumb and incompetent as a nurse. I don't know how I will face this at work tomorrow. Not to mention we do this thing called line up at the start of shift where we discuss things that are going on in the hospital and on the unit and we talk about bad mistakes that nurses make throughout the hospital. I'm sure this is bad enough to be talked about during line up.

Although they don't say the name of the person who made the mistake I know everyone will know it was me, and of course, I will know it's me they're talking about! What makes it even worse is they read the same scenarios in a line up every day until a new situation happens that they can add to the lineup discussion. I will be so embarrassed every time they talk about this in the lineup. How do I come back from this? I feel like the worse person and nurse ever. I can't even think straight. I still don't know what penalty I will face yet but I'm praying I don't get fired.

Lastly, the worst part of this situation is. When it was time to hang the potassium my charge nurse caught me off guard because I was already anxious and nervous and asked me what I would run the potassium at if it was 50ml per hr, just to be sure I would hang the IV correctly. I accidentally said 25ml instead of 50ml because I get so nervous when I'm caught on the spot and asked questions. I'm sure she thinks I'm a complete idiot. I feel like my life is ruined!! IDK what to do. What if nursing just isn't the profession for me after I've worked so hard for it, I'm so distraught!

Sorry about the grammar errors. I was typing fast because I have to get to sleep so I can wake up for work tonight. I work 7p-7a.

eatmysoxRN, ASN, RN

Specializes in Med/Surg,Cardiac. Has 1 years experience.

Everyone makes mistakes. It sounds like you've learned from yours. So move on. Always double or triple check drip rates.

This isn't making mathematical sense. If only 75 ml had infused over 3 hours the rate would have been set at 25, not one hundred.

Pangea Reunited, ASN, RN

Has 6 years experience.

(((hugs)))

I've also made a huge, humiliating mistake. It's the loneliest feeling in the world, even when the people around you are supportive and understanding and the patient is OK. I've seen over time that a lot of nurses make huge mistakes and get lucky with good outcomes, they just don't necessarily like to tell everyone about them. That can make each of us feel like we're the only one it's ever happened to.

I didn't get fired. No one really seemed to notice, actually (even though I self-reported to the patient's MD and my nursing supervisors). Of course, I thought very hard about what I'd done wrong and how I could keep it from ever happening again. That's really all we can do after the fact.

I hope everything works out OK for you. Just remember that you are not alone. Great nurses are only human and sometimes make horrible mistakes. Luckily, many of those mistakes are correctable- like mine ...and like yours.

meanmaryjean, DNP, RN

Specializes in NICU, ICU, PICU, Academia. Has 40 years experience.

Your life is not ruined, and you WILL recover from this. EVERYONE makes one of these high-stakes errors sooner or later. Your was sooner. You have clearly learned from your mistake, and will be hyper-vigilant in the future. The patient is ok.

Be grateful that you were supported - and move on.

You are not the worse nurse or some such ever. What you are is human and a new graduate nurse which means mistakes sometimes happen.

The important thing is you caught your error, took corrective action and followed proper procedures afterward. It would a bit more troubling if you didn't notice the error and or became defensive about things afterward.

Don't worry about what other nurses think about you in this situation. If any of your co-workers can honestly stand up and say they were perfect out of the starting gate and have been so ever since then maybe we can talk.

Take a deep breath and put this down to a learning moment. In future what will you differently? If you feel comfortable that you won't be stabbed in the back ask a co-worker to check your numbers before hanging a bag.

On the bright side, there is nothing like a good ole fashioned med dose error to start the adrenaline running. It also brings home the serious nature of your profession and will *hopefully* give you the kick in the pants to be more careful in future. *LOL*

I'm sorry it wasn't over 3 hrs. I received the medication from pharmacy around 3:55 am and 75ml had gone in by 5am. I remember this because I had to draw a PTT at 5am which is why I noticed the error when i went in the patient's room. So it actually was just about an hour, if that makes a little more sense.

PediLove2147, BSN, RN

Specializes in Pediatric Cardiology. Has 7 years experience.

I guarantee you will always double check your infusion rates from this point on. Don't be too hard on yourself, everyone makes mistakes. It sounds like you caught it pretty early on and were able to fix what came of it.

limaRN, BSN, RN

Specializes in ICU/CCU/CVICU. Has 3 years experience.

Take a deep breath. I have made a pretty bad error as well and I know how you're feeling. It's a lonely, guilty, sick to your stomach kind of a feeling. The pt was eventually ok and that is what matters. You were honest and owned up to it which is very difficult. You are not a bad nurse, you are human. It will get better with time. Just keep your head high!

psu_213, BSN, RN

Specializes in Emergency, Telemetry, Transplant. Has 6 years experience.

I knew an experienced nurse who was hanging a cardizem drip. It had 125 mg in 125 mL D5). For the dose, rather than entering the correct value (10 mg/hr, which would be a rate of 10 ml/hr) she entered the volume to be infused (125 mL). So the pt got all 125 mg of cardizem in one hour. Thankfully, no harm to the pt. The point is, this error was a "biggie" made by an experienced nurse. It happens. You learned your lesson, now move on and make sure to carefully check those drips.

Julius Seizure

Specializes in Pediatric Critical Care.

You learn and move on. It's ok. The patient is ok. I know it's embarrassing, but you did the RIGHT THING by self-reporting and putting the patient first. Good job! People will forget about it sooner than you think. The best thing to come out of this is this: someday you will be orienting a new grad nurse, and will be teaching them about always having someone double check your drips or any high-risk meds. And you can tell them your story.....they can learn before making the mistake themselves. Nurses are human. You made a mistake, but you did the right thing to fix it.

HUGS to you. Listen, everyone makes mistakes. Just last weekend at work, an experienced nurse gave a medication in the am, that was written for pm. It happens!!! The patient is fine, you owned it right away, it doesn't make you less of a nurse. It makes you human. And I would bet my life that you will double and triple all infusions from here on it. Try to relax now!

SNB1014, ADN, RN

Has 4 years experience.

Depending on the specific degree of med error, our facility makes the RN go to a quality assurance briefing.

Did you say that the labels are hard to read?

Maybe this is something you can bring up in a quality meeting. It is not making excuses if you earnestly believe the labeling is confusing. Perhaps it is.

Perhaps you need to focus more intently. Who knows. That's why its a review. 🙂

Best of luck,

CapeCodMermaid, RN

Specializes in Gerontology, Med surg, Home Health. Has 30 years experience.

You all stand around at the start of the shift and discuss everyone who's made a mistake? That sounds just plain horrible and doesn't serve any purpose. Learn from your mistake, be thankful no one was harmed, and move on.

lmccrn62, MSN, RN

Specializes in Pain, critical care, administration, med.

Stop beating yourself up. We have all made mistakes and the best lesson out if it is we will never make that mistake again. Don't worry what others think and this is a benefit to your peers to hear of errors. We often get lazy and at times cocky we need these lessons learned as a way for us to be paying attention.

VivaLasViejas, ASN, RN

Specializes in LTC, assisted living, med-surg, psych. Has 20 years experience.

The only nurses who say they've never committed a med error are either fresh out of school or lying.

Also, there are two kinds of nurses: the kind who've made a med error, and the kind who will.

Learn from this, and move forward. You did all the right things in following up on your mistake, and the patient is OK. It could've been a lot worse if you hadn't caught it as quickly as you did. You did fine. And I think it's a safe bet that you'll never make another one like it. :yes:

Indy, LPN, LVN

Specializes in ICU, telemetry, LTAC. Has 5 years experience.

I've seen patients get 80 mg IV Lasix as an IV push, given over oh, ten minutes or so... Of course for those patients, there was backup potassium ordered. There should have been as well, for your patient on a Lasix drip. It takes a day or two to get over the adrenaline rush (bad rush, it's scary as heck) of a med error but just analyze, remember how you made the mistake and avoid doing that again. You are doing fine. You caught it, figured it out, reported it, fixed it, didn't kill the patient, and the next step is to go back to work and hold your head up, and just work. It'll be all right in the end.

I misread a computer printout from a dinosaur system when I was brand new, checked it twice with my preceptor, and gave mag citrate to a dude who was only gonna have an upper GI and only needed to be NPO after midnight. What a fun night. Lesson learned: don't be in too big a hurry to make someone poop all night, make sure they REALLY need it first. I was embarrassed, the patient was 10 lbs lighter in the morning, but it all worked out.

Edit to add: they fixed the computer instructions very shortly after that.