Two med errors... I'm sick!

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I just got off orientation (10 days LTC). It was my second med pass on this floor. I don't usually work on this unit, and it was only my 2nd med pass alone since off of orientation.

I gave Coumadin to a resident that was on hold untill the next day. I didn't realize the arrow was pointing to that date. I realized when I went through the book later to make sure I signed everything off. I informed the supervisor on at that time. (3-11) She had me fill out an incident report.

During the narc count, the oncoming Nurse realized I gave 2 0.5 ativan instead of 1mg. I did not see the 1mg card. I know she got the right dose, but it was another careless mistake on my part.

I am sick to my stomache, did not sleep all night wondering If I screwed anything else up. I am going into the DON to talk to her today and make sure everything is okay. Am I just new and inexperienced or just plain careless. Everyday I go in wondering If I am fit to be a nurse, I feel like I do not know anything. So afraid I'm not going to know what to do is something major goes wrong. I am so sick over this.

How do you know if you are really cut out to be a nurse? Maybe I'm just not compitent enough. I don't want to put anyone else in danger.

Thanks for listening,

Bea

Specializes in LTC.

The Ativan isn't even a med error at all! Right dose, just two halfs instead of a whole..anyone wanting to split hairs on that one is just..well..hair splitting.

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just called the DON to come and talk about the incident, she asked I would like to wait untill next time I am on (tomorrow) I said, "No, I want to talk about it now" she said come in after lunch. I am going crazy. think I may have forgot to sign off on some meds... I'm second guessing everything now.

What can I expect when I go in? Will there be a meeting with anyone else besides us?

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Specializes in Oncology.

I remember when I once had a night where I made a dumb mistake. I stressed about it. I then made another dumb mistake. I couldn't believe I made two mistakes in one shift! I trusted the nurse I was reporting off to and openly told her about both mistakes. The next night I got my patients back from her. She told me about a 3rd mistake she discovered I made.

I wouldn't even count the 2 1/2 mg Ativans instead of 1 1mg Ativan a mistake as the "5 rights" were still followed.

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Deep breath....First off..congrats for staying alive in LTC. I've been doing LTC for more years than I like to admit. It is very demanding and just being able to think straight after some shift is a win.

Before you go into the meeting..think about how it happened and what could have been and should be done differently next time. When I get an order to hold a med, we turn the cards around in the drawer and right hold on the MAR nice and big.

The ativan...that isn't really an error. Has anyone looked in the narc drawer of LTC med cart??? Horrible...some people have mulitple cards for the same meds but could be at differnt times or one is prn and one is straight....it is a night mare.

What I do to organize mine or make it easier to find what I need is to turn the cards that are DC's around, turn the cards that are standing orders around after I use them or when I give a prn and can't give it again...it eliminates a lot of looking thru cards when trying to find the meds. I try to remember to turn them around when we count at the end of the shift so I don't get weird looks...hey..its my system and it works!

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Specializes in ER, ICU.

It happens to everyone, and it really sucks. I think you will be paying even more attention from now on. Just don't get complacent in the future, good luck.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

:hug: Don't beat yourself up.....like others have said. We ALL have made mistakes. I have a problem with "HOLDING" meds especially coumadin. Coumadin should be ordered everyday. I know in LTC that is a high expectation in lieu of the fact they don't have daily labs that dictate dose. The coumadin should then have a DC order and a restart/call for dose order for the next day.

The Ativan giving 2 0.5's may not be a dose error but I see what you mean about an attention to detail issue. My advice.....take a deep breath in.....let it out. and again....now being new it takes time to get out all the kinks and lose the nerves. When you go to pass meds...take your own pulse first to remind yourself to slow down a smidgen and focus. Your nerves are getting the best of you. Deep breath in, Deep breath out....

You called your DON to talk or did she call you? Either way, apologize for the mistake, recognize that you have a lot to learn, as her for any suggestions and let her know you are torn up about this and will be extra vigilant from now on....it's ok to be human...:redpinkhe

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Sister, let me tell you about my first med error. It was my FIRST night off of orientation in the ER. They were short handed and took me and another new RN off orientation early and let us work an area by ourselves. We had a little old lady come in via ambulance and was very combative. The other RN had went to take a patient to the floor. The doctor ordered 0.5mg Ativan IVP. I drew up the 2 ml/2mg that was in the vial and was waiting for the other RN to come back so I could waste before pushing. About that time the patient starts to go crazy and I started her IV and forgot that I hadn't wasted yet and gave her the entire 2mg. I immediately freaked out. My charge nurse didn't thank goodness but the patient's doctor was a complete jerk about it to me. The patient's family on the other hand said it was the best sleep she'd had in years! Mistakes happen and you learn from them. Don't beat yourself up. No one was hurt and you will know what to look for next time. Let it go and learn from a mistake.

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The way the coumadin order should have been transcribed is that the word HOLD should have been written through all the dates it was on hold. Whoever transcribed the order made the mistake, not you. So there's that.

You gave the right dose of Ativn, it wasn't a med error. If you had given one tab of the 0.5 mg, that would have been an error, but your brain was working pretty well to not just grab that card and pop out an 0.5 and give it without thinking.

If the patient was supposed to be getting 1 mg, that 0.5mg card should not have even been there. so you actually exceeded expectations there, because the wrong dose of a med card in the cart is a med error waiting to happen, even to the best of nurses, and you managed to give the correct dose.

Please don't beat yourself up about this very minor issue, you have learned something here, which is how easy it is to have potentially bad errors happen when even the best nurses out there are trying to do everything right.

Mistakes do not happen in a vacuum.

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The coumadin order said hold with a line all the way through to the 12th, but I thought it was at the 11th.

The ativan lady, does have an order for 1mg. prn... the 0.5 was her am dose. I didn't look good enough, I saw the 0.5 and automatically grabbed it, when I checked after popping one, is when I noticed it was the 0.5 not 1mg :(

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Specializes in pediatrics, public health.
The ativan lady, does have an order for 1mg. prn... the 0.5 was her am dose. I didn't look good enough, I saw the 0.5 and automatically grabbed it, when I checked after popping one, is when I noticed it was the 0.5 not 1mg :(

Please stop beating yourself up about the ativan!!! You gave the right dose! If anything, you should be giving yourself points for noticing immediately that it was just 0.5mg, instead of giving her the 0.5mg pill thinking it was 1mg -- now that would have been a med error. There is NOTHING WRONG with giving a 1mg dose of ativan as 2 0.5 mg pills!

As for the coumadin -- lesson learned. When you meet with the DON, maybe you can suggest ways to make it even more obvious in the chart that a med is on hold. In any case, you won't make that mistake again!

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Thank you all for your support :) I called the DON today, and went in and talked to her. She asked me what happened, how I overlooked it, and then said " now what can you learn from this?" "what are you going to do next time to prevent this?"

I did tell her that I am so nervous when I come to work evderyday and that I don't feel confident. She told me that for a new grad and for the short time that I have been working I am doing fine. If I felt I needed more orientation that is fine, but it is not going to help with the meds. I told her I still wanted to work a couple of days with someone just to get my confidence back and help me with some of the thins I feel not sure about.

so... two days more for me. I really want to be a good nurse and I'm so afraid I just may not be detail oriented enough. But I want to learn to be!!

Thanks to you all nice folks :):redbeathe

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Don't beat yourself up. No one was hurt and you will know what to look for next time. Let it go and learn from a mistake.

*Erin, thanks for the personal story. makes me feel better knowing other people have made similar/if not worse mistakes. ( that doesn't sound very nice, but you know what I mean)

Bea

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