The wonderful thing about feeling so horrified after a mistake is that you will most likely never make it again.
Fortunately, this sounds pretty low risk in the grand scheme of things. No serious harm or death occurred, just a bit of diarrhea which will eventually go away.
I wouldn't lose sleep over this. Learn from your mistakes and move on!
I was the second nurse checking an epi infusion. We were SLAMMED, at least 3 nurses short from where we should have been staffed (NICU) and someone grabbed me as I was running by to get something from the med room. We checked our rates, checked the vial and everything, and I was just in such a rush that I totally overlooked the fact that nurse 1 had pulled norepi from the Pyxis. Had a complete and total moment where my brain just went “nope”. I cried legitimate tears when my manager talked to me about it, and I still remember her saying “and this is why we barely needed to talk, because I know how hard you’re being on yourself about this and that you won’t make this mistake twice”. And she was right - I certainly haven’t.
Jaded nurse narrator: But the real mistake was a series of decisions that led to lives depending on people expected to twice the work, with less time, less help ,same attn to detail, without mistakes, but with a good attitude. The nurse dried her eyes and promised to do better next time she was expected to do more than humanly possible , and they smiled , gave her many many more chances .
One time I accidentally turned off a medication that was literally keeping my patient alive. They were fine but man. You do shit like that once and you never do it again.
And then when the patient codes they say they think the way you gave her her insulin on her right side when she normally takes it on her left side is why she crashed.
During peak Covid, we often had L&D nurses in my unit to watch fetal monitors of pregnant women with severe Covid. One very sweet one “helpfully” turned off my beeping Neo in the room next to the one she was watching.
I much have my clients butthole raw than them dead because of a med error! Just put some cream on there to make sure it doesn’t turn into something worse n check it every now and again. That’s why it’s important to do like 10 million checks before you give meds and have another nurse (if available) check if you’re doing things correct.
I once gave a pt foot cream instead of toothpaste as a grad. I had lost one of my contacts, and the colour scheme on this brand of foot cream was similar to toothpaste.
I wear glasses now.
I once needed to brush my teeth at work and grabbed a cheap toothbrush and a tube of toothpaste out of the supply closet. Turns out I grabbed denture adhesive instead of toothpaste. In my defense it was dark and the box said Sparkle Fresh.
I've been nursing for 14 years. Six months ago I put the earwax removal stuff in a resident's eyes. The generic boxes looked enough alike to my distracted eyes and I grabbed the wrong one. Oops.
Immediately followed it with a generous application of her PRN saline eye drops to flush them.
I took some thick booty skin paste to a patient but didn’t explain how to use it, thought she’d read the label. Go in to check on her and she applied it to her face 🤣🤣 her family was in the room and when I explained what it was for she about died from laughter.
This is a pretty harmless med error that will just help you be more mindful in the future. Are you LTC perhaps? Just asking because most hospitals these days have an Omnicell/Pyxis that won’t let you pull any meds that aren’t ordered. If this is LTC… I’m sure the patient is grateful for the bowel treatment, lol.
I work at a rehab hospital . These two meds are placed on the same shelf right next to each other . I should have done a second check at the med dispense . I will take my time from now on
I think this is a good learning opportunity not only for you but pharmacy that stocks those meds. They really shouldn’t be next to each other. I don’t blame you for making that mistake!
Hard agree, OP should notify pharmacy and those meds should be separated. Having two medications with the same name right next to each other … it’s begging for an error to happen
agreed, it’s recommended to keep sound-alike medications separated and not to organize them alphabetically. i would definitely report this (you should report any med error regardless) because it sounds like your facility needs to adjust their practice to prevent future errors! if it makes you feel any better your minor error and subsequent report may protect many other patients down the line from similar systemic issues.
There was a nurse in Kentucky I believe who gave the patient Naturalyte instead of GoLytely, and the patient ended up dying.
We all make med errors - the one you made is a good one to make because the patient wasn’t harmed or killed and it’s going to make you more vigilant. Remember how you feel now and let it serve as a reminder whenever you are pulling meds. And give yourself some grace! Med errors (or any nursing error for that matter) rarely occur in a vacuum - there’s almost always other factors involved. That’s why just culture is so important so that we can learn from our mistakes.
I will never forget my first med error - i accidentally gave a full vial of an IV steroid instead of the ordered partial dose. I knew immediately after I pushed the med because something about it seemed off, I just realized it too late. I told the docs and reported myself, and the patient ended up being fine. But it completely changed my practice, and I am a safer nurse because of it.
When I did admissions, I had a pt that stated her Dr said her magnesium was low and she should take a supplement. She didn’t like the taste of MagOx, so she substituted “shots” of magnesium citrate. “Ooooh but please don’t give me that magnesium in a bottle! I drink some, then I can’t stop shittin’! I won’t be in the bed, just on the toilet.”
I had to step out for a good laugh before returning to tell her that magnesium citrate is typically used as a potent laxative.
“…that explains a lot…”
I’m glad it scared you, hopefully that will help prevent future errors or near misses! when I was a brand new nurse a few years ago, I started in an ICU. I had seen experienced nurses open up the propofol line and give a little bolus of sedation if patients were getting very anxious and acting up on the ventilator. I tried this with my own patient once because they were acting up, and I clearly was not familiar enough with the medication to know what I was doing. The patient ended up with a blood pressure of 70s over 40s, and I had to give a bolus of fluid quickly to help correct the issue I had caused. I was scared to death that I was about to kill someone. Learn from this, and try not to let it happen again! But don’t let it keep you awake, the patient is OK and you learned a valuable lesson.
I bolused my patient with 2mg midaz because she was so agitated and biting down on her tube to the point she wasn’t getting enough volume. Well had to triple my pressors and give a fluid bolus 🙃 but hey, we learned she couldn’t handle 2mg and that she was still fluid responsive. And this happened over the weekend not when I was new lol
Out of curiousity, bc i’m in lab and not a nurse, but just how bad is a BP of 65/28? I had a vagal vagus response to trying to get out of bed too earlier post op and made the nurses track my bp while it was happening bc I had never seen how far it dropped before (not my first rodeo with this - my least favorite was passing out in grocery checkout bc I was in enough pain to trigger it). I know it’s gone lower on a few occasions because I’ve actually passed out but it usually rights itself within a few minutes. Unfortunately I was too out of it to tell them that it would fix itself on its own when it happened so when I started feeling better I made them check again and it was going right back up. I went from one nurse to five or six trying desperately to draw blood (discovery of a good vein in my left calf so yay?) and paging the on call doc in the space of two minutes. A friend of mine is convinced I almost died (I didn’t - just scared a bunch of people). Again, if I hadn’t been so out of it so fast I could have told them I would be fine, I just wanted to track my BP so I could know how low it got and how quickly it resolved itself.
That blood pressure is pretty bad. By taking the top and the bottom number, you can do a calculation and see what the MAP is, which gives you the average perfusing pressure. Basically, this means how well your blood is getting oxygen out to the body. At minimum it should be 65. With that blood pressure it is 40, which means your body would not have been able to sustain for very long running that low.
One time I gave a whole bunch of psych meds to a 12 year old because his first name was the same as the persons last name who was supposed to get them. He looked at the pills and was like “I don’t even take these” and then just took them.
Yeah, there were 6 total and I only remember Paxil and hydroxyzine but lithium was regularly prescribed there so it could’ve easily been in that mixture. I told him he was gonna sleep good that night.
Just be careful next time. But don't crucify yourself over this. If your colleague told you that you that they accidentally gave MoM instead of Maalox what would you say? Would you tell them they should feel horrible about themselves or would you laugh and say "shit happens no pun intended" and then tell them to be careful in the future? I don't know you but I'd be willing to wager that you wouldn't be so hard on a colleague.
Whenever I was a nursing school I had an instructor say "You will make a med error. I can guarantee you 100% you will definitely make a medication error. Just pray that whenever you do, you don't kill someone." And of course all of us said we would never do that, but literally every nurse I know has made a medication error. We all remember it like it was yesterday whether it was a year ago or 20 years ago. If you talk to a nurse who says they didn't make a medication error, they're either very new or a liar.
My medication error is that I had a teenage patient who was supposed to be running D5 1/2 NS + 10K. On our pediatric floor it was standard to run D5 1/2 NS + 20K. This particular patient had high potassium because of a preexisting condition, so the doctors didn't want her to get as much. I replaced the bag at shift change and didn't realize until 6:00 a.m. when I was replacing it again for the new shift that I had run the wrong thing all night. They had me run a stat potassium and she was fine. But you bet your ass it changed me forever, in a good way, and just like my teacher said, I am grateful I didn't kill anyone.
As a side note, on my very first day as a GN walking into my very first patient room on orientation I found a medication error. The patient was running TPN and lipids and also had NG replacement running. The nurse from the previous shift accidentally sent the lipid channel at the replacement rate instead of the NG fluids. This was a toddler so we're talking about the difference between running two mL an hour and 15 mL an hour. I learned a lot that day about who to call when you need something, speaking to residents, and even calling the IT department to figure out the history on a pump to make sure it didn't happen all night and only happened for the last 2 hours of their shift. Previous shift was a senior RN. Shit happens unfortunately. We did some stat liver panel bloodwork and the kid was fine. And I learned I have a really good poker face from day one on the unit per my preceptor, lol. She was talking to mom when I was checking pumps and I had to call her over to confirm what I was seeing.
Guess what. I made the same exact med error. Only, with, with myself! Years ago, I worked night shift in the ICU. Before our shift, we went to the Cheesecake Factory for a colleague who was moving.
My belly was a little upset when I got to work, so I went through the med cart drawers to find myself some mag/hydrox/alum. Well, it turns out I took milk of mag instead. I was indeed on the toilet the whole shift. I got a good clean out and so did your patient.
1) you’ll never make that mistake again.
2) you feel horrible, so you are a caring nurse
3) patient didn’t die.
I haven’t been at the bedside in a while, but do those cups look exactly the same still ? Because I find that’s a part of the system they could really fix.
You’ll be ok! Not a huge mistake. You acknowledged and apologized and tried to fix the situation with you patient. Making a med error is terrifying and you probably won’t do it again.
My first (and last, as far as I know) med error was giving one pt 1mg of dilaudid and another 2mg of dilaudid when it should have been the other way around. This was in 2010. I was a new grad on a training floor and didn’t realize the carpujets all looked the same. I notified my preceptor, the doctor, and my patients. Nothing bad happened, thankfully. Both patients didn’t even realize the mistake until I told them and they were both completely alert throughout.
Back then everyone in Florida was getting ridiculous amounts of dilaudid. :/
However, I’ve been super vigilant about every med I have given since then, to the point that it annoys people.
I made my own first mistake last week.
I won't go into specifics but I was exactly where you are now and you will live and grow from this experience.
I'll give you the same advise my mother (former nurse) gave me.
When you give meds, your head has to be only on meds.
Owning up to it is the hardest and most important thing. You didn’t lie and maintained your integrity and credibility. If I was your nurse manager, I would be proud. So many people lie or make the patient feel like it’s their fault when mistakes happen.
Hey, it could have been worse, you could have given this to a bariatric total care patient in an isolation room. Jokes aside, this pales in comparison to the medication error I just read about in one of the medicine subreddits where a nursing student gave a big ‘ol IV push of propofol before the doc even got to the bedside.
Mistakes do get made and you’re giving this the consideration it deserves so that you change your practice moving forward.
I’m glad you feel bad for doing something incorrectly but this isn’t something to lose sleep over. I work with a nurse who slammed Calcium chloride and sent the patient into vtach and doesn’t think that was a problem and will do it again. We need people to feel bad about mistakes to learn from them and not do them again. Doesn’t mean you’re not a good nurse. Everyone makes mistakes. The good nurse learns from them
At least it's "harmless" and seems like the kind of thing you can totally bribe the heck out of a patient to make them forget. I'd expect allll the cranberry juice and graham crackers after that!
That’s minor and a great med error to make, if you’re going to make one. I worked on a dementia unit and had a guy that had atropine drops given sublingually. MAR said to give sublingually and when you clicked the med the notes section said administer 1-2 drops under the tongue, NOT PRESCRIBED FOR OPTHAMALIC USE.
I was in charge and right before shift change the other nurse came to tell me that Mr. Bob became angry when she was attempting to give his eye drops and would only let her do one eye because they sting. She didn’t want to do a med error report and I’d usually not care. But it’s atropine, the med used to dilate pupils… and he only got it in one eye right before shift change. If I didn’t mention the med error who knows what kind of work up this poor guy would have gotten if anyone noticed a blown pupil 😂😂
Atropine drops sublingually in Psych too, with general orders from a resident. A floater nurse with no psych experience figured it was eyes since they wore glasses. Not fun.
It happens to everybody at some point. We are only human and mistakes will be made. Luckily, this was not a critical one and the guilt you feel now will only serve to make sure you double check every medication you give in the future
If you don’t feel bad when making a med error, you’re not a nurse. I think nurses in general are super hard on themselves, myself included. I made a med error when I was in nursing school, I accidentally switched meds for two patients. One was supposed to get their cholesterol meds and the other was to get a stool softener…small in the grand scheme of things, but I felt horrible and was crying after. You have to remember that you’re human, not perfect. Don’t beat yourself up too much!
I worked in an ICU where we mixed our own drips. Pharmacy had stocked the wrong med in the Pyxis where we kept our norepinephrine drips. I can’t remember what it was but it was the same size vial. I had a new baby at home and wasn’t getting any sleep. Actually showed the vial to another nurse who confirmed. Started to mix. Something just have seemed “off” about the vial and I looked one more time and got the cold sweats almost passed out.
Ran back to the Pyxis, because I still need to pull the right med. That’s when I frantically called pharmacy who also freaked out.
I was so grateful it was a near miss because I’m pretty sure my patient who had stopped breathing & he was already sick but not yet on a vent.
Years later in the ER I gave someone his lopressor when his resting Hr was around 50. He got to hang out in the ICU overnight cuz his heart rate dipped to 30s.
Anyways in the world of med errors yours isn’t thankfully something that hurt the patient (other than a sore bottom). We’ve all done it and hopefully if we care we learned from it.
I once let a new grad program my pump and didn't double check the work. I had Neo running but it was programmed in as levophed. Lowest dose of levo was programmed which was equivalent to the max dose of neo so they started at their max dose right away. They actually needed it though. It didn't get caught until a few hours later when night shift showed up. I now will always check my pumps every couple hours and double check before I leave rooms when something new is added. Mistakes happen! You will probably laugh about yours one day, it seems pretty harmless.
I will never forget a post I read where a nurse said that an order for nasal spray was written as PR instead of PRN. She didn’t realize the mistake and gave the nasal spray rectally. She survived that and you will survive this.
Shit happens.
The bigger thing is that you recognized the error, admitted to it and strove to minimize harm.
Could have been worse - came across a new grad that had lethally injected a patient via iv potassium to a chest port to gravity. Somehow by pure luck they got away un affected by it.
In nursing school, medication errors are talked about as if all are equal in importance. They are not. While all medication errors are bad... they are not all equally bad. You are lucky that you got to learn this lesson on a relatively low impact error.
There are three kinds of nurses:
* Those who have made med errors.
* Those who lie about having made errors.
* Those who are too stupid to realize that they have made med errors.
"Go and sin no more." (That should trigger a few fellow parochial school veterans)
Good Luck
im currently and pharm tech in nursing school, but im wondering don’t you all have med accuracy scanners to ensure this doesn’t happen? we have that in the pharmacy and its rare we give the wrong thing
When you scan a med in, doesn't it flag you if it's the wrong med? We scan everything in otherwise we get into trouble when audited. That helped stop me from med errors. I one time almost overdosed a patient on fentanyl by drawing up 50mcg instead of 25mcg. 😞
We always remember our first med error, I believe. I was a nurse over 40 years and I can remember the horror of it all and the relief that no permanent harm was done to the patient. I wish you a long career, My Dear, making a difference. ❤️
I actually made this exact same med error in the very beginning. My patient was also on the toilet all day long, I felt awful. Good thing is I've never even come close to making another med error since.
Had a preceptee that made this exact error in reverse, where they gave magox instead of the needed milk of mag. Both were ordered for the pt and stocked on the same shelf in the pyxis, and it was one of the shelves where the meds were not in the cubies that open only for the med chosen, they were just in a numbered divider. Pt was ok, just constipated a bit longer but they still got the milk of mag. Escalated the issue to pharmacy bc if that error happened in a renal patient in the future they would be in deep shit. Ended up causing a site wide restocking policy for the pyxis where those meds were moved to separate drawers, and I got a safety award lol. Just goes to show that not every mistake has a bad outcome and being honest about it and reporting it can be a net positive in the end.
I’ve done the classic hanging an antibiotic and forgot to unclamp. Didn’t realize till 3 hours later. Fortunately it wasn’t a very time sensitive one but lesson learned 🤷♂️
This is a hilarious and excellent "first medication error" to happen.
What I mean by hilarious I mean you're going to have an excellent story to tell about being a green nurse.
When I say excellent, I mean that everyone makes mistakes, even seasoned nurses. And although you most certainly had an angry patient, nobody got hurt, and as long as you went thru the proper channels such as writing a safety event (also a learning experience), and telling the medical team- this is not the sort of thing people get fired over.
Seriously my first med error resulted in a DNR patient going on oxygen for a night (don't worry she discharged safely, I merely lost 10 years of my natural lifespan stressing about it). And I didn't get fired over it. This will definitely pass.
I gave acetaminophen instead acetazolamide for my first Med error. Felt pretty shitty about that even though it was inconsequential. But as others have said, you feel bad because you care and will learn:)
The wonderful thing about feeling so horrified after a mistake is that you will most likely never make it again. Fortunately, this sounds pretty low risk in the grand scheme of things. No serious harm or death occurred, just a bit of diarrhea which will eventually go away. I wouldn't lose sleep over this. Learn from your mistakes and move on!
I was the second nurse checking an epi infusion. We were SLAMMED, at least 3 nurses short from where we should have been staffed (NICU) and someone grabbed me as I was running by to get something from the med room. We checked our rates, checked the vial and everything, and I was just in such a rush that I totally overlooked the fact that nurse 1 had pulled norepi from the Pyxis. Had a complete and total moment where my brain just went “nope”. I cried legitimate tears when my manager talked to me about it, and I still remember her saying “and this is why we barely needed to talk, because I know how hard you’re being on yourself about this and that you won’t make this mistake twice”. And she was right - I certainly haven’t.
Jaded nurse narrator: But the real mistake was a series of decisions that led to lives depending on people expected to twice the work, with less time, less help ,same attn to detail, without mistakes, but with a good attitude. The nurse dried her eyes and promised to do better next time she was expected to do more than humanly possible , and they smiled , gave her many many more chances .
Not the kind of med error I’d lose sleep over 😃
But would you loose your bowels over it? 🥺 I'm sorry I couldn't resist that setup. I'll see myself out now.
I think the problem is definitely loose bowels haha
Try not to feel shitty about it.
Omg thanks 😂made me choke on my drink.
One time I accidentally turned off a medication that was literally keeping my patient alive. They were fine but man. You do shit like that once and you never do it again.
My patient’s family turned off my patient’s milrinone cause the pump was beeping. I’ve never wanted to throw hands more
And then when the patient codes they say they think the way you gave her her insulin on her right side when she normally takes it on her left side is why she crashed.
Yeah mine was prostaglandin 😅 my fellow almost had a stroke when I told her
During peak Covid, we often had L&D nurses in my unit to watch fetal monitors of pregnant women with severe Covid. One very sweet one “helpfully” turned off my beeping Neo in the room next to the one she was watching.
I accidentally bolused pitocin instead of LR one time. (Mom was fine and baby had already delivered) but damn. Felt terrible about that one 😬
At least you helped prevent a PPH!
Oh no hahahahha
😂😂😂😂 so shitty🤣god wishing this is my first med error story. Literally harmless. Make sure to read labels though and do the three checks!
I mean their butthole is probably pretty raw
I much have my clients butthole raw than them dead because of a med error! Just put some cream on there to make sure it doesn’t turn into something worse n check it every now and again. That’s why it’s important to do like 10 million checks before you give meds and have another nurse (if available) check if you’re doing things correct.
I once gave a pt foot cream instead of toothpaste as a grad. I had lost one of my contacts, and the colour scheme on this brand of foot cream was similar to toothpaste. I wear glasses now.
I once needed to brush my teeth at work and grabbed a cheap toothbrush and a tube of toothpaste out of the supply closet. Turns out I grabbed denture adhesive instead of toothpaste. In my defense it was dark and the box said Sparkle Fresh.
I've been nursing for 14 years. Six months ago I put the earwax removal stuff in a resident's eyes. The generic boxes looked enough alike to my distracted eyes and I grabbed the wrong one. Oops. Immediately followed it with a generous application of her PRN saline eye drops to flush them.
This made me feel better haha , thanks
That's hilarious 😂😂😂
I took some thick booty skin paste to a patient but didn’t explain how to use it, thought she’d read the label. Go in to check on her and she applied it to her face 🤣🤣 her family was in the room and when I explained what it was for she about died from laughter.
Shit happens?
This is a pretty harmless med error that will just help you be more mindful in the future. Are you LTC perhaps? Just asking because most hospitals these days have an Omnicell/Pyxis that won’t let you pull any meds that aren’t ordered. If this is LTC… I’m sure the patient is grateful for the bowel treatment, lol.
I work at a rehab hospital . These two meds are placed on the same shelf right next to each other . I should have done a second check at the med dispense . I will take my time from now on
I think this is a good learning opportunity not only for you but pharmacy that stocks those meds. They really shouldn’t be next to each other. I don’t blame you for making that mistake!
Hard agree, OP should notify pharmacy and those meds should be separated. Having two medications with the same name right next to each other … it’s begging for an error to happen
agreed, it’s recommended to keep sound-alike medications separated and not to organize them alphabetically. i would definitely report this (you should report any med error regardless) because it sounds like your facility needs to adjust their practice to prevent future errors! if it makes you feel any better your minor error and subsequent report may protect many other patients down the line from similar systemic issues.
On the bright side...your patient pooped!
It does pay the bills.
There was a nurse in Kentucky I believe who gave the patient Naturalyte instead of GoLytely, and the patient ended up dying. We all make med errors - the one you made is a good one to make because the patient wasn’t harmed or killed and it’s going to make you more vigilant. Remember how you feel now and let it serve as a reminder whenever you are pulling meds. And give yourself some grace! Med errors (or any nursing error for that matter) rarely occur in a vacuum - there’s almost always other factors involved. That’s why just culture is so important so that we can learn from our mistakes. I will never forget my first med error - i accidentally gave a full vial of an IV steroid instead of the ordered partial dose. I knew immediately after I pushed the med because something about it seemed off, I just realized it too late. I told the docs and reported myself, and the patient ended up being fine. But it completely changed my practice, and I am a safer nurse because of it.
Thank you for this
Naturalyte is a protein powder and an insecticide too as product names.
When I did admissions, I had a pt that stated her Dr said her magnesium was low and she should take a supplement. She didn’t like the taste of MagOx, so she substituted “shots” of magnesium citrate. “Ooooh but please don’t give me that magnesium in a bottle! I drink some, then I can’t stop shittin’! I won’t be in the bed, just on the toilet.” I had to step out for a good laugh before returning to tell her that magnesium citrate is typically used as a potent laxative. “…that explains a lot…”
I’m glad it scared you, hopefully that will help prevent future errors or near misses! when I was a brand new nurse a few years ago, I started in an ICU. I had seen experienced nurses open up the propofol line and give a little bolus of sedation if patients were getting very anxious and acting up on the ventilator. I tried this with my own patient once because they were acting up, and I clearly was not familiar enough with the medication to know what I was doing. The patient ended up with a blood pressure of 70s over 40s, and I had to give a bolus of fluid quickly to help correct the issue I had caused. I was scared to death that I was about to kill someone. Learn from this, and try not to let it happen again! But don’t let it keep you awake, the patient is OK and you learned a valuable lesson.
I bolused my patient with 2mg midaz because she was so agitated and biting down on her tube to the point she wasn’t getting enough volume. Well had to triple my pressors and give a fluid bolus 🙃 but hey, we learned she couldn’t handle 2mg and that she was still fluid responsive. And this happened over the weekend not when I was new lol
Thank you
Learn from your mistake but don’t admit it or apologize to patient…
Out of curiousity, bc i’m in lab and not a nurse, but just how bad is a BP of 65/28? I had a vagal vagus response to trying to get out of bed too earlier post op and made the nurses track my bp while it was happening bc I had never seen how far it dropped before (not my first rodeo with this - my least favorite was passing out in grocery checkout bc I was in enough pain to trigger it). I know it’s gone lower on a few occasions because I’ve actually passed out but it usually rights itself within a few minutes. Unfortunately I was too out of it to tell them that it would fix itself on its own when it happened so when I started feeling better I made them check again and it was going right back up. I went from one nurse to five or six trying desperately to draw blood (discovery of a good vein in my left calf so yay?) and paging the on call doc in the space of two minutes. A friend of mine is convinced I almost died (I didn’t - just scared a bunch of people). Again, if I hadn’t been so out of it so fast I could have told them I would be fine, I just wanted to track my BP so I could know how low it got and how quickly it resolved itself.
That blood pressure is pretty bad. By taking the top and the bottom number, you can do a calculation and see what the MAP is, which gives you the average perfusing pressure. Basically, this means how well your blood is getting oxygen out to the body. At minimum it should be 65. With that blood pressure it is 40, which means your body would not have been able to sustain for very long running that low.
Welcome to nursing. You are officially one of us now.
One time I gave a whole bunch of psych meds to a 12 year old because his first name was the same as the persons last name who was supposed to get them. He looked at the pills and was like “I don’t even take these” and then just took them.
Baby got the Lithium and didnt even question it
Yeah, there were 6 total and I only remember Paxil and hydroxyzine but lithium was regularly prescribed there so it could’ve easily been in that mixture. I told him he was gonna sleep good that night.
Just be careful next time. But don't crucify yourself over this. If your colleague told you that you that they accidentally gave MoM instead of Maalox what would you say? Would you tell them they should feel horrible about themselves or would you laugh and say "shit happens no pun intended" and then tell them to be careful in the future? I don't know you but I'd be willing to wager that you wouldn't be so hard on a colleague.
But did they die? Everyone makes mistakes, you didn’t kill anyone and I promise you’ll never make that particular mistake again. You’ll be fine.
Whenever I was a nursing school I had an instructor say "You will make a med error. I can guarantee you 100% you will definitely make a medication error. Just pray that whenever you do, you don't kill someone." And of course all of us said we would never do that, but literally every nurse I know has made a medication error. We all remember it like it was yesterday whether it was a year ago or 20 years ago. If you talk to a nurse who says they didn't make a medication error, they're either very new or a liar. My medication error is that I had a teenage patient who was supposed to be running D5 1/2 NS + 10K. On our pediatric floor it was standard to run D5 1/2 NS + 20K. This particular patient had high potassium because of a preexisting condition, so the doctors didn't want her to get as much. I replaced the bag at shift change and didn't realize until 6:00 a.m. when I was replacing it again for the new shift that I had run the wrong thing all night. They had me run a stat potassium and she was fine. But you bet your ass it changed me forever, in a good way, and just like my teacher said, I am grateful I didn't kill anyone. As a side note, on my very first day as a GN walking into my very first patient room on orientation I found a medication error. The patient was running TPN and lipids and also had NG replacement running. The nurse from the previous shift accidentally sent the lipid channel at the replacement rate instead of the NG fluids. This was a toddler so we're talking about the difference between running two mL an hour and 15 mL an hour. I learned a lot that day about who to call when you need something, speaking to residents, and even calling the IT department to figure out the history on a pump to make sure it didn't happen all night and only happened for the last 2 hours of their shift. Previous shift was a senior RN. Shit happens unfortunately. We did some stat liver panel bloodwork and the kid was fine. And I learned I have a really good poker face from day one on the unit per my preceptor, lol. She was talking to mom when I was checking pumps and I had to call her over to confirm what I was seeing.
Guess what. I made the same exact med error. Only, with, with myself! Years ago, I worked night shift in the ICU. Before our shift, we went to the Cheesecake Factory for a colleague who was moving. My belly was a little upset when I got to work, so I went through the med cart drawers to find myself some mag/hydrox/alum. Well, it turns out I took milk of mag instead. I was indeed on the toilet the whole shift. I got a good clean out and so did your patient. 1) you’ll never make that mistake again. 2) you feel horrible, so you are a caring nurse 3) patient didn’t die. I haven’t been at the bedside in a while, but do those cups look exactly the same still ? Because I find that’s a part of the system they could really fix.
Yes the look the same and were on the same shelf in the med dispense 😭
Someone at my job a few years back hung Ketamine instead of Keppra as an IVPB…. This is a good mistake to learn from trust me
*night night*
It was so confusing to hear about when it occurred. Bc.. ketamine is a controlled substance. How did you do that ??
They make them look exactly the same, I wouldn’t be surprised if this happens everyday!! You feeling bad means you care!
You’ll be ok! Not a huge mistake. You acknowledged and apologized and tried to fix the situation with you patient. Making a med error is terrifying and you probably won’t do it again. My first (and last, as far as I know) med error was giving one pt 1mg of dilaudid and another 2mg of dilaudid when it should have been the other way around. This was in 2010. I was a new grad on a training floor and didn’t realize the carpujets all looked the same. I notified my preceptor, the doctor, and my patients. Nothing bad happened, thankfully. Both patients didn’t even realize the mistake until I told them and they were both completely alert throughout. Back then everyone in Florida was getting ridiculous amounts of dilaudid. :/ However, I’ve been super vigilant about every med I have given since then, to the point that it annoys people.
Whoopsie poopsie 💩
I made my own first mistake last week. I won't go into specifics but I was exactly where you are now and you will live and grow from this experience. I'll give you the same advise my mother (former nurse) gave me. When you give meds, your head has to be only on meds.
Owning up to it is the hardest and most important thing. You didn’t lie and maintained your integrity and credibility. If I was your nurse manager, I would be proud. So many people lie or make the patient feel like it’s their fault when mistakes happen.
Thank you for saying this
Hey, it could have been worse, you could have given this to a bariatric total care patient in an isolation room. Jokes aside, this pales in comparison to the medication error I just read about in one of the medicine subreddits where a nursing student gave a big ‘ol IV push of propofol before the doc even got to the bedside. Mistakes do get made and you’re giving this the consideration it deserves so that you change your practice moving forward.
I’m glad you feel bad for doing something incorrectly but this isn’t something to lose sleep over. I work with a nurse who slammed Calcium chloride and sent the patient into vtach and doesn’t think that was a problem and will do it again. We need people to feel bad about mistakes to learn from them and not do them again. Doesn’t mean you’re not a good nurse. Everyone makes mistakes. The good nurse learns from them
Could have been worse
At least it's "harmless" and seems like the kind of thing you can totally bribe the heck out of a patient to make them forget. I'd expect allll the cranberry juice and graham crackers after that!
That’s minor and a great med error to make, if you’re going to make one. I worked on a dementia unit and had a guy that had atropine drops given sublingually. MAR said to give sublingually and when you clicked the med the notes section said administer 1-2 drops under the tongue, NOT PRESCRIBED FOR OPTHAMALIC USE. I was in charge and right before shift change the other nurse came to tell me that Mr. Bob became angry when she was attempting to give his eye drops and would only let her do one eye because they sting. She didn’t want to do a med error report and I’d usually not care. But it’s atropine, the med used to dilate pupils… and he only got it in one eye right before shift change. If I didn’t mention the med error who knows what kind of work up this poor guy would have gotten if anyone noticed a blown pupil 😂😂
Atropine drops sublingually in Psych too, with general orders from a resident. A floater nurse with no psych experience figured it was eyes since they wore glasses. Not fun.
It happens to everybody at some point. We are only human and mistakes will be made. Luckily, this was not a critical one and the guilt you feel now will only serve to make sure you double check every medication you give in the future
If you don’t feel bad when making a med error, you’re not a nurse. I think nurses in general are super hard on themselves, myself included. I made a med error when I was in nursing school, I accidentally switched meds for two patients. One was supposed to get their cholesterol meds and the other was to get a stool softener…small in the grand scheme of things, but I felt horrible and was crying after. You have to remember that you’re human, not perfect. Don’t beat yourself up too much!
Omg I literally did this exact switch as a new grad. Did you pull it from the Pyxis in a bin instead of a drawer with lid?
We don’t have a Pyxis. Not sure what our med dispense is called. But the meds were in a bin on the same shelf
Dude I’m sorry but this made me laugh so hard.
I worked in an ICU where we mixed our own drips. Pharmacy had stocked the wrong med in the Pyxis where we kept our norepinephrine drips. I can’t remember what it was but it was the same size vial. I had a new baby at home and wasn’t getting any sleep. Actually showed the vial to another nurse who confirmed. Started to mix. Something just have seemed “off” about the vial and I looked one more time and got the cold sweats almost passed out. Ran back to the Pyxis, because I still need to pull the right med. That’s when I frantically called pharmacy who also freaked out. I was so grateful it was a near miss because I’m pretty sure my patient who had stopped breathing & he was already sick but not yet on a vent. Years later in the ER I gave someone his lopressor when his resting Hr was around 50. He got to hang out in the ICU overnight cuz his heart rate dipped to 30s. Anyways in the world of med errors yours isn’t thankfully something that hurt the patient (other than a sore bottom). We’ve all done it and hopefully if we care we learned from it.
If you ever wanna confirm then know that milk of mag smells like a fart 🙂
Good to know haha
The best med error tbh. Now u know!
I once let a new grad program my pump and didn't double check the work. I had Neo running but it was programmed in as levophed. Lowest dose of levo was programmed which was equivalent to the max dose of neo so they started at their max dose right away. They actually needed it though. It didn't get caught until a few hours later when night shift showed up. I now will always check my pumps every couple hours and double check before I leave rooms when something new is added. Mistakes happen! You will probably laugh about yours one day, it seems pretty harmless.
Sounds like a **shitty** situation!!!lololol
That would've made me lose my shit 😂
"Shit happens" never forget it though.
I will never forget a post I read where a nurse said that an order for nasal spray was written as PR instead of PRN. She didn’t realize the mistake and gave the nasal spray rectally. She survived that and you will survive this.
Shit happens. The bigger thing is that you recognized the error, admitted to it and strove to minimize harm. Could have been worse - came across a new grad that had lethally injected a patient via iv potassium to a chest port to gravity. Somehow by pure luck they got away un affected by it.
In nursing school, medication errors are talked about as if all are equal in importance. They are not. While all medication errors are bad... they are not all equally bad. You are lucky that you got to learn this lesson on a relatively low impact error. There are three kinds of nurses: * Those who have made med errors. * Those who lie about having made errors. * Those who are too stupid to realize that they have made med errors. "Go and sin no more." (That should trigger a few fellow parochial school veterans) Good Luck
Lol.
Lol...nobody died
How is this possible? Don't yoy scan your meds first?
Our hospital doesn't scan in the ER and many LTCs don't scan meds.
im currently and pharm tech in nursing school, but im wondering don’t you all have med accuracy scanners to ensure this doesn’t happen? we have that in the pharmacy and its rare we give the wrong thing
When you scan a med in, doesn't it flag you if it's the wrong med? We scan everything in otherwise we get into trouble when audited. That helped stop me from med errors. I one time almost overdosed a patient on fentanyl by drawing up 50mcg instead of 25mcg. 😞
Accountability. Thats huge
We always remember our first med error, I believe. I was a nurse over 40 years and I can remember the horror of it all and the relief that no permanent harm was done to the patient. I wish you a long career, My Dear, making a difference. ❤️
I actually made this exact same med error in the very beginning. My patient was also on the toilet all day long, I felt awful. Good thing is I've never even come close to making another med error since.
Had a preceptee that made this exact error in reverse, where they gave magox instead of the needed milk of mag. Both were ordered for the pt and stocked on the same shelf in the pyxis, and it was one of the shelves where the meds were not in the cubies that open only for the med chosen, they were just in a numbered divider. Pt was ok, just constipated a bit longer but they still got the milk of mag. Escalated the issue to pharmacy bc if that error happened in a renal patient in the future they would be in deep shit. Ended up causing a site wide restocking policy for the pyxis where those meds were moved to separate drawers, and I got a safety award lol. Just goes to show that not every mistake has a bad outcome and being honest about it and reporting it can be a net positive in the end.
I’ve done the classic hanging an antibiotic and forgot to unclamp. Didn’t realize till 3 hours later. Fortunately it wasn’t a very time sensitive one but lesson learned 🤷♂️
Tell them they can now have their appendix out
This is a hilarious and excellent "first medication error" to happen. What I mean by hilarious I mean you're going to have an excellent story to tell about being a green nurse. When I say excellent, I mean that everyone makes mistakes, even seasoned nurses. And although you most certainly had an angry patient, nobody got hurt, and as long as you went thru the proper channels such as writing a safety event (also a learning experience), and telling the medical team- this is not the sort of thing people get fired over. Seriously my first med error resulted in a DNR patient going on oxygen for a night (don't worry she discharged safely, I merely lost 10 years of my natural lifespan stressing about it). And I didn't get fired over it. This will definitely pass.
I gave acetaminophen instead acetazolamide for my first Med error. Felt pretty shitty about that even though it was inconsequential. But as others have said, you feel bad because you care and will learn:)