That was the response of my manager when I sat down in front of her to tell her that the med cup full of pills that was for the patient in bed 1032 was handed to and swallowed by the patient in 1034.
It’s 15 years later and I still get sick to my stomach and weak in the knees thinking about it. I watched that patient swallow the pills, looked down at the cup in my hand and said “Oh my gosh. I think I just gave you another patient’s pills.”
And I went straight to the care coordinator on the floor and told her what happened. She said to get the list of meds given and notify her doctor. I did that. He rolled his eyes and did nothing. I had given the patient an antihypertensive and her blood pressure started to drop. “Sir, her blood pressure is 100/60 and it was 130/76 this morning. He groaned, annoyed and said “Ok, give her half a liter of NS and put her in Trendelenburg.”
Everything turned out fine in the end, but I sure don’t like remembering this event and when I do, my response feels almost as strong as it did the day it happened. At some point every nurse feels like saying “Forget this. I’m going to work at a gift shop where no one’s life is in my hands.”
So what do we do when mistakes are made?
The first step would be to STOP administering the wrong medication, if it is IV. The next step would be informing the physician so that any antidote/repair measures can be taken as quickly as possible. This step should occur either before or after informing your supervisor, who can also help determine the best course of action. Be aware of your facilities policies. Some hospitals now have an open disclosure policy due to findings that admitting mistakes does not increase incidence of legal action.This will help you determine whether or when the patient should be informed.
Those are things which I hope are obvious. Here’s the trickiest part for most nurses: dealing with it internally. You may be one of those fortunate types that feels that the term “nobody’s perfect” is true not only for everyone else, but for yourself. Congratulations. I would say you are darn near self-actualized. For the rest of us, there is the knee knocking, mind-shattering realization that we are flawed and that our mistake could have harmed another person.
Note the use of the term “mistake” and not “failure.” In most cases, this is not the end of your nursing career, nor should it be the end of your peace of mind.
There is a fine line between having anxiety about giving meds and being cautious when giving meds. The former should not be a daily factor and the latter should. Feel free to double, triple check or even ask a coworker to check meds with you. Don’t forget the ten rights of medication administration. Take a deep breath and take your time. Ask for help if you are getting overwhelmed. Finding someone to talk to is often very consoling. If anxiety begins to hinder your job performance, talk to your supervisor. Your facility may have resources available for you.
Be grateful for the system of checks in place. This time consuming process prevents you from making the mistake I mentioned at the beginning of this article. Barcode scanning has reduced the number of nursing errors in medication administration. If you are not in a setting that uses the newer technology (nursing homes, schools or rural settings) then come up with a system for your personal use that gives you peace of mind when administering meds.
Remember that everyone does make mistakes. Learn from yours. Use it to grow and become a better, more aware nurse.