Worst Medication Error of my life

Specialties Cardiac

Published

Well, I have worked as a Progressive Care Nurse Cardiology since graduating in 2010. My patient started to have chest pain, nitro sublingual was ORDERED and given. The chest pain was still unrelieved, 2 mg morphine iv ORDERED. Morphine was not available after waiting 5 minutes. The physician looking at me stating he needs his morphine. I webt to the Pyxis to find no morphine, I then override to obtain the morphine immediately. To my surprise I selected VERSED and administered in errir 2 mg At the time iI am also trainin a new graduate nurse. I felt so...bad. The physician notified on the floor, patient was fine (Thank God). We do not give consious sedation medication on our unit. Why was I able to pull this medication? Regardless, I am responsible. What will I be faced with during a peer review at my hospital?

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

When you over ride you will be able to pull meds from your machine (depending on the machine set up). You might have a peer review depending on your facility. We all make mistakes....now think of ways you can prevent this mistake in the future? Having a new grad didn't cause the error.....it is simply the five rights...((HUGS)) we all make mistakes. They key is learning form them and not repeating them.

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Thank you for your insightful and encouraging words. I have learned from this situation, although I still feel dissappointed in letting my trainee down. I want the peer review to be over already. The patient continues to be progressing well. He said, "We are still the best nurses he's ever had." Great patient! I leave everything in God's hand, He is my strong tower.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Thank you for your insightful and encouraging words. I have learned from this situation, although I still feel dissappointed in letting my trainee down. I want the peer review to be over already. The patient continues to be progressing well. He said, "We are still the best nurses he's ever had." Great patient! I leave everything in God's hand, He is my strong tower.

Of course they are((HUGS))....Versed/Midazolam is a very short acting drug. Your trainee got some valuable lessons....one....ANY ONE can make a mistake and two...you own up to them and learn from them. Neither of you will forget this experience.

The peer review IF, and the is a big IF, they have one..... is just to examine what happened and how to prevent it in the future.

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Specializes in Emergency, Telemetry, Transplant.

My guess is that you carry versed in case someone needs "emergency" sedation, such as for an emergent cardioversion (although, in that case, it should be in the crash cart only, not the pyxis). Reading nursing journals and hearing some of the med error stories on here, this is by far NOT the worst med error I've heard of. It happens. Learn from it, but move on. If it does come to a peer review, bring up the question of why the versed was in the pyxis--don't make it sound like you are trying to make an excuse for your action. This is a legitimate safety issue and it should be addressed.

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Specializes in NICU, ICU, PICU, Academia.
Thank you for your insightful and encouraging words. I have learned from this situation, although I still feel dissappointed in letting my trainee down. I want the peer review to be over already. The patient continues to be progressing well. He said, "We are still the best nurses he's ever had." Great patient! I leave everything in God's hand, He is my strong tower.

You taught your orientee a PRICELESS lesson- that no matter how experienced the nurse, errors can happen, and that is WHY certain procedures are put into place.

Can I offer a suggestioon? When I pull anything fro PYXIS- I hold the actual med up to the screen, compare the screen and the label and say the name of the med aloud- as a further protection against error.

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I really don't like having to override on the Pyxis because it's way too easy for errors to happen... I was a new grad, maybe a month off orientation, and had to pull morphine STAT for a patient from Pyxis as an override. Well I was extremely lucky that I did all my checks because it was lorazepam, (in the morphine section)! Two of the three I had to pull were lorazepam... I was so shaken up because I almost gave it, this was to be an IM on a palliative pt and I noticed when I looked at all the labels that two were one color and one was different. It taught me a good lesson about checking my meds but I also realized I was very, very close to giving 2 vials of the wrong medication...

I feel for you. Med errors happen and they are scary (even almost errors are scary), but the fact that you care that you made the error is a good thing. I know nurses who think it's no big deal if no harm comes... It's hard when a doctor is wanting something now or our pts need something now and we just want to make them better, more comfortable whatever it may be. It's easy to rush and skip steps, I'm sure we've all done it without realizing it and just got lucky. You didn't. All you, and all of us can do is slow down and remember we have all those checks for a reason. It sounds to me like you are a great nurse who made a mistake, and taught your orientee a great lesson at the same time.

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Specializes in PeriOp, ICU, PICU, NICU.

Hugs! You won't be the first or last and thankfully you will probably never make mistake again. Pt is ok thank goodness and learn from this experience and build from it.

All the places I have worked versed comes in a dark vial and morphine in a carpuject syringe. Maybe in the peer review (if you have one), it could be suggested they carry similar.

Much luck

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I just wrote a paper on Med errors and nursing. They are using the term "second victim" for us now. The patient is the first ( I know it was an accident) and we are the second because it mentally tears us up and makes us suffer, 1 from making the error and 2. worrying about the patients 3. the discipline related to the error. I hope everything works out for you, we aren't perfect but we try to be. The best of us make mistakes.

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Thanks to everyone who gave their heart felt words of encouragement. This sight has really allowed me to open up without being ridiculed. Nothing but professional-straight talk.

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I've made a similar error ....huge, although the patient was unharmed. It also revolved around pulling the wrong medication from the pixis while being in a hurry. I know how terrible and alone you may be feeling, but you are not the only one this has happened to.

(((hugs)))

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Specializes in OR.

I think giving versed wasn't a terrible mistake! I wouldn't want to remember having chest pain anyway!

((HUGS)) This too will pass....

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