What I learned from my first med error

[HermioneG, BSN, RN]

Hi everyone,

I had my first med error the other day, and I noticed a lot of threads on here of people discussing their first med error and what happened. It was a huge comfort for me to read through the different threads and realize that #1 I wasn't alone, and #2 that there are certain things I could learn from other's stories that will help me avoid future med errors myself.

I wanted to share my story and what I learned (long post alert!) in the hope of helping other others. I also wanted to give a platform for anyone else to share a med error that they've made as well as what they learned (only if they wanted to, no pressure). I made a list of what I learned and will be sharing it with the other New Grads at work, so I figured I might as well share here too.

I'm currently a New Grad in the Emergency Room, and we are cross trained in both the adult and pediatric emergency rooms, and the error occurred when I was doing a shift in the Pediatric emergency room.

Right before shift change, I got a verbal order for "1 of morphine" for my patient (I will explain the quotes later). The attending and resident were at bedside doing a procedure and I had my preceptor and a float nurse in the room with me so I felt very safe, relaxed, and not alone. My preceptor pulled the prefilled 2mg/1mL of morphine and I went to give it. I looked at the label, saw "morphine" read the label and then I saw that there was 1 mL in the syringe. I told my preceptor that I was going to give "1 of morphine." I took my flush, walked into the room, and gave it bedside. It wasn't until after I gave it and came back to the computer that I realized my mistake. In pushing 1mL of the medication, I had actually given 2mg. I couldn't understand how I had read it wrong, and I remember just staring at the empty syringe in complete shock and disbelief. I knew it was supposed to be mg, but in letting my guard down and making critical mistakes I had equated that to mL.

My preceptor immediately told the doctor and we monitored the patient. The patient ended up being fine, but it was absolutely terrifying. The only way I can describe it is that it reminds me of what went through my head the first few moments after I was in a bad car crash. I just stood there, stunned and completely nauseated. There were a few wild and nonsensical moments where I thought to myself "this can't be happening" and "there has to be some way to rewind this…" and then "can't I just undo it? Suck it out somehow?" before coming to the quick realization that no, I can't undo it. It's done. Then I experienced a few fleeting moments where wanted to run away, hide, and never come back. But you can't do that either. The bell has been rung, impact has happened, now stand up and face it. So you immediately let the doctor know and go up the chain of command, notify your team, and stand there and face the music.

I stuck it out for the last ten minutes of my shift, monitored the patient, gave report, and then went to my supervisor. The doctor was gracious and the verbal order was changed to 2mg, but I knew I had to be honest about my error. Full disclosure and honesty is always the best policy. Telling my supervisor was one of the scariest things I've ever had to do, but he was kind. He took me to the supervisor's office to fill out an incident report and another supervisor sat with me and shared the story of his first med error. I was completely devastated and couldn't stop crying. Then my preceptor came in and sat with me as I filled out the report (I had told him that I wanted to be the one to tell my supervisor). He told me of his first med error and gave me a hug. Then another supervisor came in to use one of the computers and I told her and she told me "it happens sometimes" while being really supportive. I felt embarrassed and ashamed and terrified but I was met with nothing but love and compassion from everyone. I went home, texted my educator (who replied that she already knew, to not beat myself up, that we all make mistakes, that I'm still a good nurse and amazing person, etc). I cried all night, and then decided that I can either let this mistake ruin everything that I've worked so hard for, or I can learn from it. So I made a list of what went wrong. The first two are really obvious and I fully realize that, but I wanted to say them anyways.

1) The first thing that I did wrong was that I dropped the units of the medication when verbalizing it. It was the very end of the shift and I was exhausted. On previous shifts I had let myself slip up here and there during report and drop the units ("I gave 0.5 of dilaudid, I gave 2 of morphine, etc). Now, when I was dead on my feet, I let my guard down for just one minute and dropped the units without realizing it. The doctor saying "1 of morphine" was fine because I knew exactly what he meant, but I need to be safe in my own personal practice and always verbalize units. It was terrifyingly easy to get mixed up once I let myself not use units. I looked down, saw "1 of morphine" and in fact gave the patient 2 mg instead of 1 mg. I will NEVER drop units again. Even in report. It just makes for bad habits and is too risky. Always use units. Always. Especially if you're going to give a medication IV, it needs to be "I have x mg in y mL, I need x mg so I need to give y mL" Don't make my mistake. I know most of you guys are going to read this and point out that this is very obvious, but mistakes happen and our brain gets tired… In those moments its critical to have good habits to fall back on. In that moment I didn't realize that I was doing it, but I did, and all it took was one time of saying "1 of morphine" to completely screw up and put the patient at risk. Never again.

2) Similar to #1 but always read the label out loud. Follow a script every time "I have x mg in y mL of z medication." Instead of doing that, I looked down, saw the medication, and said "I have 1 of morphine." That is worlds different from looking down and saying "I have 2mg in 1 mL of morphine" and then "I want 1 mg of morphine so I need 0.5 mL." I knew to always read the label out loud, and always did. This is the first time I didn't. But all it takes is one time of letting your guard down. Always read it out loud, never in your head. I read the label but didn't verbalize it EXACTLY as it was, and had I done that I might've avoided a mistake.

3) Speaking of letting your guard down, I felt too comfortable for my own good. I had two doctors at bedside, my preceptor, and a float nurse in the room. All was calm, and there was no immediate rush to give the medication. It was nearing shift change, things were quiet, and the patient was stable. We had been slammed the entire day but things were winding down to a comfortable pace. I used to think of medication errors as happening when you're rushing or in an emergency. While that's true, they're also high risk when everything seems well and you feel safe. Back to car crashes, it reminds me of how a high percentage of car crashes happen within miles of a person's house. Why? Because the person feels comfortable. I had four other people with me and felt more comfortable than had I been the only one in the room. This is dangerous. If you're the one giving the med it might as well be only you in the room because you're the last line of defense that patient has against a med error. Don't fall into the trap of feeling comfortable and safe. Double and triple check always. Don't let yourself fall into a false sense of security (and by you, I mean me... most of you guys probably don't do this I'm more preaching to myself here).

4) One of the supervisors shared with me that what helped him was to either dilute the medication whenever the patient can tolerate it, or pull it up into a separate syringe. Be extra careful of pre-filled syringes. From now on I'm not going to be using pre-filled syringes in a non-emergency. I'm going to take the time to pull it up in a separate syringe and consider dilution as an added precaution. I'm going to do that from now on because from this experience I believe that "interacting" with the medication more by purposefully diluting or pulling into a different syringe can decrease the chance of medication errors (or at least in my own belief from this situation).

5) Lastly, verbalize the dose that you're going to give to the patient and/or parent. I told the parent "I'm going to give morphine for pain" when I should've said "I'm going to give 1mg (emphasis on units) of morphine to your child for pain." It can be the last wake up call to make SURE you're giving the correct medication and dose.

I know that all of these things are things that we've been taught already and that we should do regularly. I realize that I dropped the ball, made a big mistake, and made critical and obvious errors. I take full responsibility for my mistake, and the fact that I made this mistake terrifies me. But I'm determined to learn from it and never make it again. Even though this advice is pretty obvious, I wanted it to serve as a reminder for anyone who wants one. I've always been hyper-vigilant with medications, but all it took was one time. I had to identify the painfully obvious ways in which I messed up so as to never do that again. Deep down, I don't think I'm ever going to fully stop beating myself up over it...

Best wishes,

HermioneG

[YumCookies, BSN, RN]

Thank you for posting your experience. The worst med error I have ever encountered was when I had a patient that had an insulin drip on one pump and on another pump had IVF and apparently had an IV med run as a secondary during day shift. When I was about to change the bag of the insulin drip three hours into night shift, I realized the medication attached to the pump was an antibiotic. I looked at the rest of the patient's IV setup and found the insulin bag connected to the IVF as a secondary.

I completely freaked out - naturally. I wanted to puke, cry, and poop my pants all at once. Thank freaking GOD my patient was alive. I felt pretty crappy for not catching this sooner but I was grateful the patient was okay. I knew I needed to move on from this to get through the rest of my shift and care for my other patients.

Anyways, I think what completely baffled me the most is this drip went on for several hours with two RNs cosigning to titrate the drip every hour, merely looking at the medication and rate on the pump. Since this incident, especially with high alert IV medications, I not only look at the pump but look at how everything is set up. Unfortunately we learn at our patients' expense sometimes, and the best thing you can do is forgive yourself and learn from it.

[Orion81RN]

You stated that the doctor saying "1 of morphine" was fine because you knew what he meant. However, even though it may be common, it absolutely is not fine. A prescriber should always state units. If he had done that, that may have triggered your tired brain, thus preventing the ned error to begin with. You ARE the last line of defense, but he is the first and got lazy himself.

Ill try to explain my med error, on a kid as well. I was working in an allergist office giving allergy shots. The vials with different concentrations were color coded. Each weak, we would go up 0.5 ml of one concentration until we reached the highest level for that vial. So the 1st week they got 0.5 ml. The next week 1 ml, the next week 1.5 ml and so on. Then we would use the next vial of a higher concentration starting at 0.5 ml again. (But the vial is a higher concentration of the allergen than the previous one.)

My nurse manager had apparently already prepared the next vial for the next level of concentration for one kid bc he was getting close to reaching that level. I grabbed his vial, drew up his dose, and administered it. Keep in mind I'm giving him something he is allergic to. I went to return the vial when I saw the other vial in his drawer. I immediately realized I gave the kid a high dose of the HIGH concentration instead of the low concentration. I think I injected him with 10x the amount he was suppossed to get.

Adrenaline rushed through me. I excused myself quickly, grabbed the dr. in his office right next door, never keeping my eye off the pt bc of the proximity of the dr. office to the pt. room. The dr. told me to give him benadryl, and we kept him there for 40 minutes instead of the standard 15. Thank GOD he experienced no reaction.

We did always keep epi right there in case of emergencies, but still a scary experience nonetheless. The doctor was so smooth, not letting on at all sonething could happen to avoid panic in the mom. He just talked to the kid about school, 1) keeping the environment calm, 2) assessing his airway simply by hearing the kid's voice.

I should have checked the concentration instead of focusing on ml. Plus, the NM should never have put 2 vials of differing concentrations in the same bin.

I did have to give epi to someone once, but it wasn't due to an error.

I made yet another error at that office. We had two Russian patients with the same 1st name. A name you could go a lifetime of never hearing once, let alone there being 2 of them. We worked out of 2 different locations. This ocurred at our secondary location where I was not used to working. So already Im 1) uncomfortably in the environment, and 2) unfamiliar with the patients. That SHOULD have made me more vigilant.

So the receptionist brought me the next patient's paper with his name on it. I looked up what allergen and what dose he was to receive. I called him back. I administered the allergen. I don't know what made me think to say his full name after I injected him, but I did. He then told me no, Im not So and so Whatever. I'm So and so other person with unique name. I administered the wrong med to the wrong pt because I did not properly do my pt verifications. And the receptionist had written the wrong name down. The doctor REAMED us out, very understandably. And for the 1st time he mentioned my 1st error to me which he had been very gracious about when it had first occurred.

The receptipnist felt so bad, apologizing to me over and over. I tried to reassure her by saying yes, she needed to be more careful, but it is ultimately MY fault. Im the one who went to school for this. Im the one who became licensed for this. I'm the one who did not verify the pt's full name out loud with him.

Yikes.