Ways to prevent this med error

Nurses Medications


Hey guys, so I'm a pretty new nurse. Graduated May of last year, did an 18 week residency/preceptorship program and have been on my own for roughly 5 months. I work on a very busy med/surg floor. I made a medication error on my last shift. Not a "huge" one and no poor outcome for the patient (I presume).

So they had 2.5 mg Eliquis PO ordered BID. So I was supposed to give half a tab because it came as a 5 mg tablet. I mistakenly gave the full tab. I only realized it later that morning when I was looking through the patient's drawer for something and saw a pill cutter, and it clicked to me that I had never used it. I notified my charge nurse, then notified the MD and had to fill out a sort of "incident" report. The MD just said to hold the evening dose of the Eliquis.

The patient went to Dialysis that day and I made them aware of the error as well when they returned. They were being transferred to SNF later that day and I let them know that I would be letting their nurse at the facility know this as well in report, but made sure they knew not to take ANY Eliquis that evening if given.

Anyways, long story short, how do I prevent myself from doing this again?? Do I need to mark the package or something? Any tips would be great, thanks.

Specializes in Emergency, Telemetry, Transplant.

How was it written on the MAR? Sometimes they can be a bit confusing.

Just remember--when you are an experienced nurse, don't crucify the newbie for what, at that point, you think is a "really dumb" med error.

Fortunately (because you can avoid this in the future) and unfortunately (because I'm gonna sound like a jerk), this boils down to a failure to perform the 5 Rights. I'm not being flippant, I promise. It's just that the original 5 Rights must be accomplished mindfully one way or another whether paper chart, eMAR, scanning or no scanning, or any other variable. They must be done, every time.

The part about being mindful is a trap we can all fall into. We are harried, we perform some of the same basic tasks over and over until we are sometimes doing them without the proper mindfulness.

This error which did not harm a patient will stick with you as you strive to be very purposeful in ensuring the 5 Rights are all in order when administering medication. That's the silver lining to this. :)

It'll be okay. No one was hurt, and it sounds like upon realization of your error you handled it responsibly and took measures to ensure patient safety going forward.

Take care ~

Specializes in Case Manager/Administrator.

If it was written on a MAR they can be confusing. I like to color code some things. It does come down to check and check again-5 times we check.

If the order is for Eliquis 2.5 mg BID this is quite clear...

You could write the order on the MAR

Eliquis 2.5 mg in AM

Eliquis 2.5 mg in PM

This could be 2 separate items.

When it comes to medication I am a stickler about not being interrupted as well. There really must be an emergency for me to respond to someone when I am passing meds, each person deserves our undivided attention for this task. I had some very demanding patients on a sub acute unit once...they would wheel their chair by the nurses cart, wait all 4 of them. I started to not push the cart near the dining room until I was ready to serve them first. I asked them several times to not interrupt but only 1 of them listened. I am the one administering the medication and if I am being interrupted I will stop, shut my cart and wheel it somewhere else, it is that important.

We ALL make at least one med error if we do this long enough. And kudos to you for recognizing and handling it. Sometimes it's cheaper for pharmacy to supply a 5 mg dose when a 2.5mg dose is ordered, even if you are wasting the other half of the tablet or vial. I have learned to always double check and verify that the dose on hand is the dose ordered. It is very easy to get very busy and be a little behind, and you pull the pill out of the drawer and glance at it, see that it's the right med, but not notice that it's the wrong dose.

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