Terrible Medication Error

[rekea526]

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!

[Whitesranch, BSN, RN]

It’s tough cause your a new nurse but, standard of practice is to check INR before giving Coumadin. Move on, build on knowledge, you’ll never do it again ?

[gemivrn, BSN, RN]

Hi Whitesranch,

Thanks for your comments, I did say that the order (to check the INR) prior to administering coumadin wasn't there, I was assuming that this order (that was discontinued by the other nurse) will be there but it wasn't there that day, we normally check it the anticoagulant flow sheet (the latest INR) and there would be new orders and/or new doses or new orders to hold coumadin BUT, for some reason, it has been DC, so I was assuming it was still standing order, oh well things happens/errors being made even with nurses with 20-30 yrs experience, thanks a lot again.

[purple unicirn, BSN]

I had a patient the other day and during morning  sift change the out going nurse was busy. I went in to see the patient and she was in a lot of pain . The doctor was in the room and said can you give her some pain medication. I went and got the medication and gave it to the patient. Low and behold while the patient was swallowing the medication the nurse came in and said I just gave her pain meds.

I got the pop up in the epic and wrote that the doctor was OK with the extra med.

u then called the doctor and explained what happened he was OK with the extra dose.

 The patient was fine and I called the doctor and let him know 2 hours later and the patient was discharged. Now I’m worried about an audit in epic and I will be fired I dinot do an incident report .

 

should I keep worrying or  just see what happens

 

 

[amoLucia]

Since your EHR has already identified the discrepancy, you most prob should do an incident report. Even if late, you'll be showing your accountability &it's your chance to explain the circumstances,  Just don't go pointing blame at others - try to identify where a problem occurred (like if the fire bells just went off!). 

[canoehead, BSN, RN]

If you havent made a heart stopping med error, you just havent been practicing long enough. Any nurse that admits to their error and fixes it as much as possible has my respect.