Mistakes are Inevitable: No one is perfect.

Great post Ruby!

Powerful story. Thank you for sharing!

If only that first nurse had questioned why she needed to draw up 10 vials rather than consider that a vial was a single dose! So tragic! Fortunately the computerized med scanning system is preventing many possible med errors as long as it is used! When people skip scanning the meds in an emergency or feeling rushed that is when a med error could happen. If only such a system was in use both of these errors probably would have been prevented!I agree when and if you make a mistake it is important to be honest about it and take quick action to try to avert any danger and save the patient! A nurse I worked with once put capsacin gel on a patients leg wounds not realizing it was the wrong thing and was used for arthritis, it causes a burning sensation. She denied it even though it was obvious what happened and that patient suffered pain and injury from the wrong cream. If there had been a med scanning system this could have been prevented! If you don't know what something is or does double check before giving it! Even more tragic I remember reading about an error that lead to a young pregnant mother's death when an overworked and tired nurse skipped the med scan and ended up giving a lethal dose of a med. Criminal charges were filed against her even though it wasn't intentional! Please use the med scanning system! It will protect your patient and you and your license!

Thank you!

great article and engrossing!

Fortunately the computerized med scanning system is preventing many possible med errors as long as it is used!

Both scenarios made me cringe. Literally.The difference between the two, is one nurse worried about her pt, and the other worried about her career.

I will never forget when, as a new ED nurse, I pushed 100 mcgs of fentanyl instead of the ordered 50 mcgs (our vials have 100 mcgs). As I sit here typing this out on my iPad, I remember the sick feeling in my stomach. I couldn't get out of the room fast enough and I rushed to a trusted, more experienced nurse, "oh my God, I gave twice the dose". The doctor was sitting right there and I said, "I am so sorry, I gave twice the dose." I was previously a NICU nurse and I was not as familiar with adult doses of pain medication. Sitting here now, I know I shouldn't laugh at my med error but the guy was like 350 pounds, took regular narcotic pain meds, and the 100 mcgs didn't even touch him. It it taught me a new habit though, one that I have to this day. Any med that is a "partial package" I set aside and scan, draw it up and give it separately.

I thank the Lord I haven't made a fatal mistake. I've come close though. I once gave Thorazine for a migraine too fast. It came in a piggyback bag, and my preceptor was on my ass to hurry up. I didn't pay attention to the clamp on the IV tubing, which was wide open. The patient was totally snowed. My second mistake was not putting her back on the monitor. The nurse I handed her off to found her snowed, pulse ox reading in the 70s. Got her on the non rebreather mask and eventually she came back to consciousness. She could have died from that.

Powerful and great examples. Thank you for writing this!

Quote from HikingEDRNIt it taught me a new habit though, one that I have to this day. Any med that is a "partial package" I set aside and scan, draw it up and give it separately.

This is right on time. Thank you!