What would you do- med ?- thanks!


If you are not "sure" you made a med error but think you might have, given 1.0 mL of a PO med instead of 0.9 mL on a q6h med (given twice), 2.5 mg possibly given instead of 2.25 with each dose, and it's been 2 days since you possibly made the error what would you do? (The pt is very young that's why the dose is so small). I don't know if there's a way to report "possible" error and I am truly not sure- I'd say it's a 70/30 chance that I made the error vs. didn't make it. I know it sounds stupid that I wouldn't be sure but this pt has several meds and I only realized the "possibility" the next day when drawing up the same medication- the concentration is 2.5 mg/mL. (Ironically the pt received a partial dose at one point the next day, d/t not closing one port of the GT and spilling part of the med). I have looked up the med online on reputable sources and can't find any serious issues with a higher than usual dose, though I know that is not the real issue when reporting med errors. It is metabolized in the liver and one liver enzyme was somewhat elevated about an hour after the pt received the last dose, but I don't know if that's related or not, the pt has multiple issues? I'm sorry this is so long... please help me out here. I'm not sure who else to ask.

Specializes in Pediatrics.

If anyone sees this before 6 or so tonight... I would really appreciate your opinion whatever it may be, no matter how little or much you have to say about it :) Thank you!!! :D

I would just chalk it up to a learning experience that adds to your

nursing wisdom and move on. Let it go and just be careful as you

continue your practice.

No harm done.....you are aware and will be more careful in the


It will do no good to worry yourself to death.


79 Posts

I like to sleep and it seems to be bothering you way too much,,talk to your supervisor and see what she says to do, we all make them we are human . I have always notified Dr if med error made, just document the facts. 2.25cc whatever given Dr.J notified new orders recieved. follow up chart.:idea:


24 Posts

I personally would report it, and here's why.

When errors of any kind are reported, they are also compiled, and the hospital (or any facility) can make improvements based on those errors. Maybe others have made your same mistake and they can suggest that the pharmaceutical company make a different concentration, or the packaging can be changed, or pharmacy can put a special label on the bottle.

So I wouldn't worry about your mistake since no harm was done, but I would report it just so your employer can make improvements in the med administration process.


20,964 Posts

Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis. Has 26 years experience.

I would report and chalk up as lesson learned. We ALL make mistakes.

leslie :-D

11,191 Posts

what was the challenge in drawing up the ordered amt? of course we all make mistakes, no doubt. but it's equally as important to know where/why we erred so we don't repeat it. i'm glad your pt is ok.


Specializes in Pediatrics.

ok I have to be quick... on the way out but,

One reason I might have made the error is that the conc. was written above the ordered dose on the MAR. However, on the medication the right dose was highlighted and circled. I really, really can't remember what I drew up at this point. I would never ever have realized the possibility of error if I hadn't had the pt again the next night and, I think the pt will be discharged today before I'm back again. I don't know if that has anything to do with it.

There is no way to say this that sounds appropriate, but I am afraid of the repercussions because, I have had a time period in the recent past where I had to have every single med checked w/ another RN. During that time I didn't make any errors of course. I am afraid I will be written up or put on probation for this. It's not a good way to be and I realize that, since patient safety is paramount. If it was an error I was sure of, I'd have no qualms about it, but this just makes me nervous because I don't know of a way to say "I might have made this error but I can't be sure" because, I know that sounds stupid and people will ask me "well tell me, WHY aren't you sure???" and I will have no real answer for them. And I don't want to get into a huge "thing" over something I might not even have done.

I typed this real fast so I'm sorry if it makes no sense....

I have to go at this point but if you have any more suggestions for me I will read them later and decide more what to do. I honestly am not sure what I am going to do this evening but I'll keep you posted.


24 Posts

There is no way to say this that sounds appropriate, but I am afraid of the repercussions because, I have had a time period in the recent past where I had to have every single med checked w/ another RN. During that time I didn't make any errors of course.

Why is that? Have you made errors in the past that required you being checked?

Jolie, BSN

6,375 Posts

Specializes in Maternal - Child Health. Has 37 years experience.

If you KNEW you had made an error, I would encourage you to go thru the appropriate channels to report it.

However, you don't know. I think we have all had "brain freeze" moments when we flashed back to a previous dose of meds and questioned whether we prepared them correctly, especially in NICU and peds where doses are so small and individualized. Such situations serve as warnings that we must be meticulous with each and every medication.

But to report something that may not have happened seems counter-productive to me. I have worked in institutions where such reports were used to hang nurses, not improve the system.

I would suggest speaking with your nurse manager, risk manager, or pharmacist and pointing out the ways that the pharmacy order COULD be mis-interpreted due to the confusing way it was transcribed onto the MAR. No need to "admit guilt" since you don't know if you are guilty. Approach it as a QI issue, not a med error, since one may not have been made.

And thank you for attempting to correct a situation BEFORE a patient is harmed.

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