Yuck! med error

Published

Specializes in RN.

ugh! I made a med error! I feel just sick about it! I work as an agency nurse and have been working a lot in one facility. They have a hard time finding med techs (skilled/ long term care) so sometimes I get pulled and placed on meds. The other day I was placed on a med cart and passed meds on a side that I have never worked with before. This is par for the course with agency nursing... When I came back to the same unit two days later to work the nurse manager (who I have never met on this floor) walks up to me in the nurses station and hands me some forms and says " I need you to finish these". I took the forms from her not knowing what they were, glanced over it and saw it was an medication incident report and it was on me! I almost fell on the floor! I then said to her " I knew nothing about this" She then says to me "this is me informing you and walks off". I have NEVER as a nurse been more mortified. After reading the error it appears that I signed off in error a scheduled lyrcia but then never popped it and administered it to the pt. The med nurse that passed meds after me found the error when she went to sign off the PM dose and saw that I never signed out the AM dose. I do not recall if I passed the med or not... After thinking about it there could have also been more than one card and I may have taken the med from the other card... Chances are I just failed to administer the med. I am so bummed out by this omission and thankful it was not a real serious error.

However, I am very unhappy with how this "nurse manager" treated me. I realize I am agency staff but I deserve respect. SHe came to me after I had been working in the building for two days after the error was found, and after I just finished my shift. (I have been back since but I still feel yucky about it)... I am sure if I start looking I can find something one of her staff nurses did wrong.. I just feel sick about this!

Up Vote Up Vote ×
ugh! I made a med error! I feel just sick about it! I work as an agency nurse and have been working a lot in one facility. They have a hard time finding med techs (skilled/ long term care) so sometimes I get pulled and placed on meds. The other day I was placed on a med cart and passed meds on a side that I have never worked with before. This is par for the course with agency nursing... When I came back to the same unit two days later to work the nurse manager (who I have never met on this floor) walks up to me in the nurses station and hands me some forms and says " I need you to finish these". I took the forms from her not knowing what they were, glanced over it and saw it was an medication incident report and it was on me! I almost fell on the floor! I then said to her " I knew nothing about this" She then says to me "this is me informing you and walks off". I have NEVER as a nurse been more mortified. After reading the error it appears that I signed off in error a scheduled lyrcia but then never popped it and administered it to the pt. The med nurse that passed meds after me found the error when she went to sign off the PM dose and saw that I never signed out the AM dose. I do not recall if I passed the med or not... After thinking about it there could have also been more than one card and I may have taken the med from the other card... Chances are I just failed to administer the med. I am so bummed out by this omission and thankful it was not a real serious error.

However, I am very unhappy with how this "nurse manager" treated me. I realize I am agency staff but I deserve respect. SHe came to me after I had been working in the building for two days after the error was found, and after I just finished my shift. (I have been back since but I still feel yucky about it)... I am sure if I start looking I can find something one of her staff nurses did wrong.. I just feel sick about this!

It seems to me it is more of a 'documentation' error than a med error. If you didn't sign out the med, and a med wasn't missing from the blister back, then there shouldn't be a problem. They should just give you a warning if they were really upset about it. But 'Lyrica' is one of those meds, or any locked med for that matter, that you would remember if you gave or have some idea that you gave it - you really can't pull a med from a different blister pack without signing it out. It would come out missing. Maybe explain to this manager that you were new to the floor. Be clear you didn't sign out the med/no med missing.

Up Vote Up Vote ×
Specializes in RN.

The med wasn't missing from the pack I missed administering it but signed it out in error. So its an omission error....

Up Vote Up Vote ×
+ Join the Discussion