The End Of An Era

[Davey Do]

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.

[Davey Do]

Just now, JKL33 said:

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

I think I'm going to cry...

Thank you, JKB!

 

[SmilingBluEyes]

Belinda Hang in there.

I made a doozy of a dual-medical error on two patients at the same time when I was a newer nurse.

Two patients, same last name, rooms across the hall from each other. One ordered a sulfa drug the other a penicillin.  Well I hung the drugs and felt great until I looked over the bed of the one patient and it said "allergic to penicillin" on a big red sign. Yes, you got it. I gave THAT patient the penicillin and the other the sulfa.

My knees turned to water and I felt like I was going to faint. I asked the allergic patient what happened if she got penicillin. She said she gets a "tummy ache". I probed further, "anything else?". No was her answer.

Well I got my stuff together, stopped both infusions and called the doctors. I then prepared the correct meds for the correct patients. Both received their antibiotics without incident.

Telling the doctors was hard. Telling the patients harder. But it was a real lesson that being in a hurry can cause med errors and sometimes, deadly ones.

You made an error. You are going to feel bad. But don't  kick yourself too long about it. 24 years later, I still remember this and am more careful.

Hug yourself and it will be OK.

[amoLucia]

I believe most all of us remember some time when we all made some kind of med error or such. But I've always wondered how many, if any, med errors were NEVER caught by ourselves or by others?!?!?!?!

I'd bet there were most prob some during our careers that NOBODY ever knew about.

[LibraNurse27, BSN, RN]

I follow a nurse account on instagram and they did a poll of thousands of nurses of how many had made med errors and it was 90% said yes. Then they asked if you reported the errors. 71% said yes and 29% no... interesting. Has anyone considered not reporting or actually not reported an error that didn't cause harm? As I said, I was tempted but guilt got the best of me. 

[speedynurse, ADN, BSN, RN, EMT-P]

16 hours ago, amoLucia said:

I believe most all of us remember some time when we all made some kind of med error or such. But I've always wondered how many, if any, med errors were NEVER caught by ourselves or by others?!?!?!?!

I'd bet there were most prob some during our careers that NOBODY ever knew about.

I think this is a very good point. I am sure there are multiple errors that we made in the ER with the many patients and multiple meds and drips going at once. I will be the first to say I have made med errors - but not because I am not competent but because I had too many things going on at once or was working too long a shift with overtime. 

[Davey Do]

18 hours ago, SmilingBluEyes said:

I hung the drugs and felt great until I looked over the bed of the one patient and it said "allergic to penicillin" on a big red sign. Yes, you got it. I gave THAT patient the penicillin and the other the sulfa.

I read this and immediately nervously laughed out loud, exclaiming, " Oh GAWD!"

Sometimes, The Fates smile upon us and allow us to learn valuable lessons, without too many bumps and bruises.

Thanks for sharing that harrowing story, SBE!

I've shared some of the stories I've read here on allnurses with Belinda and have let her know of your support.

She sends her appreciation.

[Davey Do]

18 hours ago, amoLucia said:

I believe most all of us remember some time when we all made some kind of med error or such. But I've always wondered how many, if any, med errors were NEVER caught by ourselves or by others?!?!?!?!

I have to humbly admit that a chief motivation for me to report a med error is the fear getting caught by someone else, amoLucia.

Reporting myself for a med error is a humbling experience in itself, but I also gained a sense of pride in reporting myself. Going against my own integrity would send me down the slippery slopes of sinfulness.

I recall a sign that hung on a wall in the CD treatment unit: "Once you've given up integrity, everything else is a piece of cake".

[Davey Do]

14 hours ago, LibraNurse27 said:

Has anyone considered not reporting or actually not reported an error that didn't cause harm?

No, I haven't considered not reporting a med error, LibraNiurse.

I have, a time or two, not reported a med error.

The last med error that I made and did not report was giving a patient a 25 mg dose of Trazodone at HS and 50 mg should have been given. The patient was RX trazodone 25 mg BID, 50 mg HS. When I was pulling the meds, I hit a BID dose on the pyxis screen instead of the HS dose. 

By the time I had discovered my error, the patient was sleeping. I was in the NS with my MN work wife Eleanor, told her, and we just said, "Oh well". 

The only other one that I remember was a smaller dose of Depakote, prescribed for a patient Dx with Bipolar D/O. By the time I found that med error, the patient had been discharged. This would have had to occur between March and July 2003, when I was working a day shift at Wrongway, because I worked MNs from July 2003 until March 2020.

Guilty as charged and I throw myself on the mercy of the court.

[Guest856929]

45 minutes ago, Davey Do said:

No, I haven't considered not reporting a med error, LibraNiurse.

I have, a time or two, not reported a med error.

The last med error that I made and did not report was giving a patient a 25 mg dose of Trazodone at HS and 50 mg should have been given. The patient was RX trazodone 25 mg BID, 50 mg HS. When I was pulling the meds, I hit a BID dose on the pyxis screen instead of the HS dose. 

By the time I had discovered my error, the patient was sleeping. I was in the NS with my MN work wife Eleanor, told her, and we just said, "Oh well". 

The only other one that I remember was a smaller dose of Depakote, prescribed for a patient Dx with Bipolar D/O. By the time I found that med error, the patient had been discharged. This would have had to occur between March and July 2003, when I was working a day shift at Wrongway, because I worked MNs from July 2003 until March 2020.

Guilty as charged and I throw myself on the mercy of the court.

Sometimes reporting these innocuous errors creates a mountain out of an ant hill. Like the one with the discharged patient in your example. The paper trail to rectify that would be quite cumbersome. I once gave senna at 1800 instead of 1600. Technically it’s a med error, but the patient was shi**ing like a goose all day. I think it’s logical to let bygones be bygones in such cases, the context of the situation withstanding.
 

I will confess that I have intentionally given lactulose 5 minutes before my shift ended instead of an hour early. I didn’t like the nurse following and the pt’s ammonium levels were mitigated. She was quite obnoxious and unnecessarily confrontational. It was the last dose before discontinuation. Next day she told me about the crappy (pun intended) shift. I felt a certain warmth in my heart that I almost cried, joyfully. 

[Davey Do]

22 minutes ago, cynical-RN said:

 the context of the situation withstanding.

Exactly.

22 minutes ago, cynical-RN said:

I will confess that I have intentionally given lactulose 5 minutes before my shift ended instead of an hour early. I didn’t like the nurse following and the pt’s ammonium levels were mitigated. She was quite obnoxious and unnecessarily confrontational. It was the last dose before discontinuation. Next day she told me about the crappy (pun intended) shift. I felt a certain warmth in my heart that I almost cried, joyfully. 

Oh, you scoundrel, you!

I could float my own boat re: patients with elevated ammonia, lithium, WBC, and one other I elevated level that I can't recall, in my last days at Wrongway, but I shouldn't throw good nurse after bad. 

[spotangel, DNP, RN, NP]

Hugs to Belinda Davey! Patient is fine and she did the right thing by reporting.All is well that ends well. Let there be peace on earth especially in Daveybelindaville! 
This too shall pass!