medication errors. my underpants are full.
By impactEDnurse • Mar 19th, 2008 • Category: reflective practice., tips and tricks
Study published in the Medical Journal of Australia, interviewed medical staff to explore some of the causes and conditions that led to medication errors in a busy Emergency Department in Western Australia.
Every medication error was associated with one, and usually more than one, error-producing condition.
Overall, 16 subjects (61.5%) reported one or more personal factors having an influence at the time of the error, including staff being busy, tired and/or engaged in multiple tasks, and hence being potentially distracted. Several admitted to feeling stressed, usually because of the heavy workload, and, in two cases, personal issues were thought to be contributory. Commonly, staff were working after hours (eight instances) or in unfamiliar hospital areas (five instances) or attending a patient who was not their prime responsibility (eight instances). Changeover in staff seemed important in four cases, and eight staff were unfamiliar with the patient at the time of the error.Problems with communication were reported by 10/15 doctors and 6/7 nurses. In the case of doctors, this was generally between teams at the time of handing over care. In the case of nurses, communication problems occurred mainly within the nursing team. Junior medical staff also reported lack of guidance from senior colleagues (seven reports), sometimes resulting from junior doctors’ reluctance to bother a busy colleague or their low expectation of receiving a helpful response to a request for advice. Two doctors felt pressured by nursing staff to increase sedation in older patients.
What are the most important things you can do to protect yourself against medication errors?
Nurse with aggressive defensiveness: the compressed and pressured zeitgeist of the emergency department is skewed to siphon potentially catastrophic errors straight into your underpants. Be vigilant always. And encourage a culture of pro-tection (yourself) and co-tection (your colleagues).
Advocate for developing an information rich environment. Easy access to current hospital medication policies, drug guidelines and relevant information at the point of medication dispensing.
Be attentive. When handling medications try to punch a little space in your multi-exponential-tasking of urgent things that need to be done hours ago. Slow down and turn on your lights.
Medication. Meditation. Nearly the same word.
Be accountable: When you do make an error (not if, but when), the worse thing you can do is to ignore it or try to cover it up. Immediately let your supervisor, the patients doctor and the patient know.
Be supportive. Nobody gets out of a career in nursing without a medication error or two sagging in their underpants. It is the worst feeling in the world. Even worse than getting a needle stick injury.
What are your own experiences with medication errors? How did you feel? Were you supported by your colleagues? What are your own strategies to avoid errors?
impactEDnurse is also known as Ian Miller, a nurse with over 26 years experience working in a busy emergency department in, Australia. This site in no way reflects the opinions of that hospital.
All stories (although based on actual experiences) have been changed to protect patient confidentiality.
Email this author | All posts by impactEDnurse
I’ve made two medication errors as an RN – the first on my first day of having a patient load in my grad program. No harm resulted from that one (gave the patient Atorvastatin at the wrong time day).
The second was a result of not picking up that my patien’t Alaris infusion pump was not actually infusing his Nimodipine at the rate that it said that it was. This hadn’t been picked up the morning shift either and he went for nearly 11 hours without the Nimodipine. The next day he went into massive vasospasm. Depite the neurosurgeons’ reassurances, I felt that this was my fault and felt sick to the core. It truely was one of the most god-awful experiences ever.
In both cases, I was well supported by my colleagues – both nursing and medical staff. As far as strategies go – check and double check – both the orders and the machinery. Lessons learnt the hard way are lessons not soon forgotten.
The second patient ended up making a full recovery, and was very understanding when I told him what had happened. His main concern was what we could do to avoid having the same thing happen again.
Open disclosure and incident reporting are good things…
I’m a student nurse in a place you might not know well (Gemany) and I’m in my first year with little to no experience. We had a busy shift on an Intermediate Care Ward and I was ordered to hang on an IV antibiotic for a patient I think it was ceferoxim.
Ringing telephone + 2 moaning patients in the room + two patient bells and a thousand other tings made me do a simple but fatal mistake. The flow rate was set too high and the whole antibiotic (250ml) was pushed into the patient in 5-10 minutes.
After about 20minutes my supervisor/mentor-nurse entered the room and the patient had swollen lips and complained about itching. Also his skin went red. My supervisor took a look at the flow rate and quickly called the doctor on duty. The patient had an anaphylactic reaction and was treated at ICU for one night. He went out of it without any affections.
My mentor told me, it is not sure wether it was my mistake or a general reaction which could be possible. But she told me that I will never do such a thing again after this experience.
This was the first time I REALLY felt that my work affects peoples live and that my awareness can be vital for my patients.
As a new MD, I appreciate the fact that pharmacists and nurses with more experience are double-checking my work, and don’t just blindly follow what’s written. I have been known to miss my calculations from time to time, though I am careful. That phone call from the pharmacy, or the half-smiling query from the nurse, is embarassing, but certainly better for both me and the patient.
I am an RN and I just made a medication error 2 days ago by giving Toradol 30 mg IVP to a patient with renal insufficiency as ordered by the ENT without checking with the nephrologist first. The patient seems to be ok so far(I was off yesterday but I called to ask how he was). But I feel so awful and guilty about it and I don’t know if I can do this again. It has completely undermined my confidence in myself as a nurse. I worked very hard to get here and it scares me to think that I could do one wrong thing that could cost someone their health or pobbisly their life.
Has anyone else ever felt this way? How do you get through it and go on? I wanted to talk to my manager about it, but she never called me back.
I made a medication error just a few days ago, gave a pt phergan instead of stemitil- generic names are really similar, was tired and rushed off my feet, and stupidly didn’t take time to triple check as I should have.
Having to tell the patient’s family was the most horrible feeling in the world. By the way, they took it extremely well (far better than me had I been in their shoes).
I was amazed by the support I received by my fellow nurses who were on…. reinforcing the good that can come out of us supporting each other. We do a pretty emmotionally and physically draining job, so lets continue to try and make it slightly easier by being there for one another.
I made my first med error ever last week. I’ve been a nurse since September, and I’m generally pretty good about my 5 Rights and whatnot.
The fluid order was NS + 20K and I grabbed the wrong bag and hung D5 1/2NS + 20K.
Not only did I do *that* stupid thing, I also stamped the roommate’s info on the sticker for the bag.
Two errors in one! I can only blame end-of-shift madness. Luckily, nothing happened to the patient. And at least she got her potassium, right?
Today I had an investigatory meeting with my manager and a union rep, and the manager is going to present the findings to the Medication Error Committee. I’m scared as hell and hope nothing too bad comes of it.
(I realize this post is from about a year ago, but I just discovered your site and I love it!)
I have been a nurse for 3 years. sometime i wonder if it was the right decision. i have really bad anxiety along with attacks, and have had a couple panic attacks in my time. i have made 2 med errors. one was doubling insulin on a total care pt, and the other was giving a pt at least 12 meds that belonged to another pt. i work in ltc and have 30 pts at a time and its so stressful. there is barely enough time to pass meds let alone provide the care the pts deserve. i got out of ltc for a long time and now ive just recently started back. i am scared to death of making a med error because i rush around like crazy just to meet the deadline. and not only that, i work on 3rds and there is only me and one other nurse in the building that split 60 pts. i am so scared one of my pts will choke or something will happen and i won’t know what to do. every night i go into work i am freaking out inside and so scared something will happen. the other nurse is on the other end of the building and doensn’t help anyone with anything. its just a scary and alone feeling. i feel like i need to hurry and go back to college and find a different career but i don’t even know where to begin
Hi Steph , I know how you feel . I also work in Ltc and have 32 pts & have felt overwhelmed like you . funny you say have anxiety , since I never had anxiety , however since I have been doing Ltc I too have had bouts of anxiety & wondered if I need to take something , however we ,must put into perspective the great work load & responsibility many Ltc facilities are putting on nurses. . I do want to encourage you not to be so hard on yourself . So you had a few stumbles , this doesnt take you out of the race . You have an enormous work load & Im sure several interuptions which can easily makes us suceptible to med errors.
I too had a similar incident of giving the wrong meds to the wrong pt – I had two pts meds poured & some one interupted me & thus I made an error … I felt so terrible , so depressed- like this career was not meant for me , however I came to the realization & acceptance that I am human . You take this terrible lesson & make darn sure you learn from It . My saying now is , one thing at a time & one pt at a time … no matter what ! I worked too hard for my license to loose it.
I have been researching other options & found that there are some Ltc homes that have a better nurse to pt ratio & more staff to assist & better organized . Also, my friend who is a nurse hated Ltc & thought she would leave the profession , then she went to home care & found here niche ,she gets a case which is only one patient. she makes her own hours & is with that one patient for 8 hours & loves it & says she will never go back to Ltc & money is better than Ltc
. Another friend went to be an office nurse & works per diem for Ltc for extra money – this seemed to help her , since when she worked full time in Ltc it was overwhelming .
I currently work 40 hours in Ltc & love the people , but feel as you do , quite overwhelmed.
After much searching I found another Ltc facility who has a ratio of 1 nurse to 20 patients , they also have a unit secretary, who fills out labs, calls family, dr etc for you & a unit manager who will assist with admissions & discharge & emergency situations. Nurses I talked to love it there & say it has been best place they worked , so I am going to apply , since I do love the geriatric population . Also you can look for employment at cardiac rehabs , dialysis, special needs, & assisted living . If you never look outside your window , you will never see what is out side . so , I encourage you to do your research and with Ltc ALWAYS ask what the nurse to patient ratio is & request to have in writing a list of your responsibilities.
You must have come to nursing for a reason , the fact that you even posted this tells me you must be a kind & compassionate person to even care . I have seen many make errors & not even blink their eyes. Last tip , do not be so hard on yourself, be kind to yourself . You must take care of yourself first. Stress & anxiety is worst enemy of your health, your peace , & a stable mind. So please , be good to yourself. If you believe in a God , ask Him to help you find the right job & ask Him for peace . good luck , wish you the best.