Med Error

  1. I just made a med error. I was floated to a unit that I have only ever worked on once before and ended up giving one patient another's medicines. Luckily they weren't major medications, just vitamin E, but then I was short for the proper patient. AND, I had to turn to the RN in the middle of the med pass to let him know what happened, in front of everyone (staff and patients). I know errors happen occasionally and the patient's names were VERY similar (same last name, same first initial) but I really hate when it does happen. I am usually extremely careful about medication passes in order to prevent something such as this happening in the first place. Have any of you ever made med errors? Or am I the only one?
    Last edit by KaraLea on Jul 9, '02
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    About KaraLea

    Joined: May '02; Posts: 1,164; Likes: 80
    Forensic/Psychiatric LVN


  3. by   jayna
    I am always always careful about medications. Let me think back....................................I didn't remember giving wrong medication to the patients.
  4. by   NurseDennie
    Kara -

    Of course you're not the only one. I don't remember the name of it, but there was a HUGE thread not long ago about this very thing. I think it was a "come on, confess" type of thing.

    The good thing about a med error like this one that only involves a vitamin (although E can be prolematical in some circumstances) is that it's a bit shock to the system and it will remind you every time you give meds in future how very bad it feels to realize that you've just made a med error.

    Don't beat yourself up over this, of course. We learn from our mistakes, and the reason "to err is human" is a cliche is that it's true!!


  5. by   shygirl
    Yes, It was my second week of working in the nursing home. There was two diabetic patients that had the same first name and same last name initial. They even LOOKED alike! and like you, I made a mistake, but mine was that I gave one the others insulin!!!

    I was so upset. I went immediately to my DON crying over what had happened. We called the MD and the families and made out incident reports. My self-esteem was shattered for awhile. But eventually I learned to double check EVERYTHING. You will too. Good luck and don't be so hard on yourself. We are humans. Shygirl
  6. by   nursedawn67
    Originally posted by NurseDennie

    Don't beat yourself up over this, of course. We learn from our mistakes, and the reason "to err is human" is a cliche is that it's true!!


    Dennie you posted exactly what I was thinking...great minds think alike!~
  7. by   Zee_RN
    Eventually, every nurse makes a med error. He or she may not even realize it. We are human, we are not computers. You learn from your mistake and you don't make that PARTICULAR mistake again.

    DO NOT beat yourself up about it; just learn from it. And keep on going; you'll do fine!!
  8. by   RN-PA
    Here's one of the threads, entitled "S.O.S" where med errors were discussed:

    Another good thread was entitled "Nursing errors I learned from...":

    You'll realize from reading them that you have plenty of company.
  9. by   hoolahan
    They should call them med accidents, b/c no one ever intends to make a mistake, it happens by accident. We are all only human!!!LIke everyone else said, learn from your mistakes, and try to move forward. Your self-esteem will be in the toilet for a while, but it will eventually pass.
  10. by   KaraLea
    I have made med errors in the past, but it has really been awhile since the last one. BECAUSE, I have been extra careful. At least it was just Vit E which that patient was on anyway, just at a lower dosage so it wasn't as bad as it could have been. My RN told me that I did right in coming to him and admitting to the mistake. He does Peer Review at times and says that you can get into more trouble for covering up the simplist error than you can if you just admit to making a mistake.
  11. by   KaraLea
    My present employers don't make a big deal out of med errors either, just write it up and go on with your job. Take care of the patients to make sure no harm was done, but they don't beat you with a wet noodle for a simple mistake.
  12. by   thisnurse
    how can anyone go thru their career and not make a med error?
    especially when you are giving so many meds to so many ppl. the hard thing is admitting it and taking responsibility for it.
    the good news is that you learn from your mistakes and you have less of a chance of making another one than many nurses.
    i was recently a pt...i found some med errors in the meds i was perscribed in the hospital.
  13. by   KaraLea
    When my mother was in the hospital after having her TAH, she requested her pain medicine and was given two "little orange tablets". Found out later that they had given her a double dose of laxitive instead of the pain med that she had requested. BOY, was she cleaned out for awhile.
  14. by   boggle
    Oh yes Karalea , I've made almost the same error you described!

    Sure some med errors happen because of STUPID mistakes, but most are a result of many factors or little errors....a breakdown of the SYSTEM.

    Because the nurse is the last person between the med and the patient, the error becomes yours!

    BUT- there are so many factors tht lead up to an error.....
    nurse overloaded, on strange units, new patients, new meds, new routines, too-long shifts, med sheets or med orders unclearly written, look alike-sound alike meds or look alike- sound alike patient names not flagged with warnings....

    I worry that folks who say they have never made a med error in their entire career may actually have just not realized they made an error.

    You did the right thing- report it right away so corrective action (for the patient) can be taken right away. Hopefully each med error helps identify changes that need to be made in the med delivery system to mad it safer!!!

    Mostly, give nurses enough time to THINK!!! , enough time to follow all the steps necessary to safely pass meds.