The End Of An Era

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Specializes in Psych (25 years), Medical (15 years).

My medical wife Belinda, who has worked in the field for over 30 years and has been an RN for 14 years, in med suge and IMU, made her first med error last night.

A patient couldn't get to sleep and asked Belinda for something. Belinda asked if the patient usually took something that helped. The patient replied, "Sometimes I take 25 mg of Benadryl".

So Belinda requested an order from the hospitalist for a Benadryl 25 mg order. The hospitalist gave a verbal order for hydroxyzine 25 mg. Belinda gave the patient Benadryl 25 mg and told me, "I had Benadryl in my head and that's what I gave." She reported the error to the hospitalist and wrote herself up. She is crestfallen.

There's no joy in Mudville- Belinda made her first med error.

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Specializes in Community Health, Med/Surg, ICU Stepdown.

Aww sorry to Belinda, med errors suck and are scary even when no harm to pt. As long as pt was not allergic to Benadryl I bet no harm. 14 years as an acute care nurse with no med errors, not even minor, I think is impressive! I hope she's not beating herself up and that it will just increase her vigilance and dedication to pt safety, which from what you described are already excellent! Hugs to Belinda and glad she has you to support her. Props to her for being honest, reporting, and notifying. As someone who made a med error last week after years of not making any, I know how bad it sucks even if pt is OK. =( 

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Specializes in Psych (25 years), Medical (15 years).
On 1/25/2021 at 11:34 AM, LibraNurse27 said:

 14 years as an acute care nurse with no med errors, not even minor, I think is impressive! 

Thank you, LibraNurse, I will relay to Belinda your kind words.

Belinda and I worked together a few times when we were both employed by Wrongway Regional Medical Center, and I've seen her in action. She was a legend at Wrongway and is so very focused, like a bulldog on a bone!

However, when Belinda is at home, that all goes out the window. I've compared her to a helium balloon without a string as she just aimlessly floats around the room, sporadically bumping her head on the ceiling.

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.

I didn't even make it 14 days without making my first mistake, 14 years is amazing! I'm so sorry that Belinda is feeling down about it, but I'm quite sure that the patient experienced no harm, especially since they reported that they take benadryl regularly. (It's too bad that hydroxyzine was ordered rather than the patient's regular med) I hope she's feeling better about it quickly!

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If there were a list of errors to make that one would have to choose, I would elect that one -25 mg of Benadryl, especially if that is what the patient usually takes. Seems like an innocuous mistake.  

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Specializes in Psych (25 years), Medical (15 years).
On 1/26/2021 at 2:39 PM, cynical-RN said:

If there were a list of errors to make that one would have to choose, I would elect that one -25 mg of Benadryl, especially if that is what the patient usually takes. 

Ditto, Cyn.

Belinda has had to deal with some heavy duty drugs and situations over the years, as many medical nurses do, and not made a mistake. I said about the same thing to her as you said in your post, inclusive of the fact that diphenhydramine and hydroxyzine are so closely chemically related.

Belinda said, "It's not the med. It's the mistake".

I agreed, and said, " I know- a med error is a med error is a med error" and added that had it been some big deal drug, she would have paid closer attention. In addition, it was midway through her third 12 hour MN shift.

Belinda's supervisor was very supportive and said, "That's another reason why the doctors need to not give verbal orders and put the orders in themselves!"

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36 minutes ago, Davey Do said:

Belinda said, "It's not the med. It's the mistake"."

I understand her sentiment, especially given that it had never happened before. I would encourage her to look at it as a lesson, rather than a regretful experience. Most of us yearn to be perfectionists, but the wise once said 'to err is human'. 

 

40 minutes ago, Davey Do said:

I agreed, and said, " I know- a med error is a med error is a med error"

I categorically disagree with this notion. There is a gaping chasm between med errors, especially relative to severity of harm.

Remember the Dennis Quaid incident where I think his twins were administered 100X the amount of heparin. Now that is a frightening error that would make one think that the nurse's actions are irredeemable, but even in that case, much was learned and when root analyses were conducted, it was found that there were many system breakdowns/inefficiencies that ranged from pharmacy to the manufacturer, yet I can bet the entirety of my existence that the nurse who administered the dosages wholeheartedly blamed herself.

I say all that to say that at times it is the incompetent system that leads to mistakes. Like you said, had the MD entered his own orders, much could have been avoided.

Lastly, there are studies (I read a few from Australia) indicating that 12 hour shifts are quite dangerous and that preventable errors are highly correlated post the 9th hour of a shift. 

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Specializes in Psych (25 years), Medical (15 years).
17 hours ago, cynical-RN said:

12 hour shifts are quite dangerous and that preventable errors are highly correlated post the 9th hour of a shift. 

Aw geez, yes!

Couple to it our chances of making a mistake on the MN shift increase up to forty per cent, and we are advised not to multitask after we're over the age of fifty!

Now, what in the Sam Hill happened to that Submit Reply button?

Belinda! Did you take my Submit Reply button?!

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13 minutes ago, Davey Do said:

we are advised not to multitask after we're over the age of fifty!

The most multitasking that I can do is reading the newspaper while performing the natural act of elimination. I credit this incompetence to being a man however. haha. 

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Specializes in Psych (25 years), Medical (15 years).
6 minutes ago, cynical-RN said:

The most multitasking that I can do is reading the newspaper while perform the natural act of elimination. I credit this incompetence to being a man however. haha. 

Will you be my allnurses brother?

Oh- or nephew. Geez, I forgot how old I was.

Maybe great nephew...

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3 minutes ago, Davey Do said:

Will you be my allnurses brother?

Yes, indeed. Hopefully a brotherhood cartoon will come forth ??

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Maybe the universe knew that it was perfect timing in her career for a little pause or reminder. And it sent one that posed essentially no risk to a patient.

So, gratitude is kind of in order.

Anyway. Send her a thumbs-up, a pat on the back, or a hug from me. Whatever she would prefer.

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