Rest assured good friend. Everyone makes medication errors. After you’ve emotionally processed the fact that you’ve just made a medication error, you need to take action. Each facility will have it’s own policy and procedure but here is a general guide to help ease through a sticky situation.
Step 0 – if the medication is infusing – STOP IT.
Note the time – it may sound strange but look at the clock and make a mental note of the time that you found the medication error and the time the medication error was made.
Tell someone. Tell your coworker, tell your charge nurse, tell your house supervisor, tell your DON, whoever would be most appropriate in your facility. This is an important step and only takes a second. You need a second set of eyes because if you’re anything like me, you’re upset and maybe not 100% on your game. Maybe they can come assess your patient with you. Maybe they can start the event reporting process. Maybe you need a second set of eyes to see if you actually made the error you think you did. Maybe they can work on getting the doctor on the phone. Maybe they can make some calls while you move on to step #2.
Assess your patient. When I say assess your patient, I do not mean delegate vitals to your nursing assistant. Go in the room as soon as possible and assess them head to toe including a full set of vitals. Ask them how they feel. Ask them if they have any new symptoms. When you call the doctor (in the next step) you need to have a solid assessment in front of you and ready to roll off of your tongue.
Call the doctor. Give a report using SBAR. Side note – I HATED SBAR but now SBAR is my FRIEND. If you haven’t heard of SBAR, a quick google search will fill you in. You sound professional and organized. You sound prepared. You seem put together and less frazzled than you might be feeling.
Prepare for them to be frustrated or maybe even a little scared themselves. Prepare yourself to take responsibility for your error. It may sound something like:
“I understand you’re frustrated and I’m frustrated with myself. Please know I will be thoroughly reviewing the error and identifying what went wrong with my supervisor. I will learn from this and work to make sure this doesn’t happen in the future.”
See how I didn’t apologize a million times over? I didn’t even apologize once in that statement. As my fifth grade teacher says, sorry doesn’t feed the bull dog. Tell them what you’re going to DO. Don’t waste their time with repeating “I’m sorry” until you’re blue in the face. They know. Be remorseful but let them know you’re taking action.
The doctor will likely give recommendations or orders such as “monitor vitals every hour for 24 hours” or “hold their evening dose of Metoprolol” or “they need to go to the ER” or they may even say, “so what?” Have a pen and paper ready!
Do some research on the medication yourself! Critically think and look up the onset of the medication. When should I expect symptoms and what should I expect?
Did you give a double dose of Metoprolol ER? You’re going to be checking vitals OFTEN but maybe not for a few hours! Did you give 2 mg of Dilaudid instead of 0.5 mg? You’re going to want capnography at bedside and have the oxygen and Narcan ready! Did you give 10 units of Novolog instead of 10 units of Lantus? You better be checking blood sugars and force feeding orange juice.
Continue to monitor your patient for adverse side effects, toxicity, new symptoms, and changes in level of consciousness. How long you monitor your patient will depend on the medication and the severity of effects the error had on your patient.
Sit down with your supervisor or charge nurse, debrief, and identify what happened. Simply put, which of the 5 rights of medication administration did you betray? Who else should be involved in the debriefing? Find the holes in the swiss cheese! (my BSN friends will get this!)
Did the pharmacy package the wrong concentration? Were you short staffed? Did the barcode not work? Was your computer down? Was the package labeled wrong? Were you distracted? Were you floated to a unit you weren’t comfortable with? Don’t BLAME others, but critically think about WHAT HAPPENED that could have been prevented.
The final step is to LEARN from your mistake. Admit to your mistake. Tell others about how to avoid your mistake. Show grace to other nurses who make a mistake. Come up with a plan to avoid the circumstances the contributed to your mistake.
Finally, forgive yourself. We are all human. We all make mistakes. We will make mistakes again. If you are struggling with your confidence or doubting your abilities or staying stuck in the “I’m so DUMB” shame spiral for too long, please reach out and talk to someone. Reach out to your education department for resources, maybe your hospitals employee assistance program to help coordinate some counseling, a close coworker or the best option yet would be your supervisor.
Within days after turning 16, I began working in the nursing home.
In that particular nursing home, the CNA’s were required to wear maroon scrubs, the nurses were required to wear white scrubs etc.
For elderly residents, this was very confusing. It was great for staff and visitors because they knew who to direct their questions too, however the residents couldn’t differentiate between the aides that were caring for them.
After my first few days on the job wearing my mom’s too small old tennis shoes, I quickly learned the value of a good fitting pair of tennis shoes. With my very first paycheck, I purchased an all black pair of Nike sneakers. They were super boring.
So, with my newly earned driver’s license and my brother’s 1987 Buick LeSabre, I ventured to WalMart (because what else do 16 year olds do) and searched for a way to spark up my plain jane sneakers.
I found a pair of pink shoelaces.
After I started wearing my new tricked out sneakers around the facility, residents started to take notice and I earned my reputation as “The girl with the pink shoelaces.” (and “the girl who sings)
One particular resident seemed to take notice, he was new to the nursing home and still had his mind with him yet. He was a very friendly guy, never married and never had kids. We’ll call him Jack.
Jack and I became fast friends. I soon “adopted” him as my grandpa. I brought my family to meet him, I planned a joint birthday party for us (our birthdays are 10 days apart), he even had to approve the guy I was dating! (he would always ask “How’s your squirt doing?” or “Are you still with that squirt?” referring to my boyfriend) I would visit him on my days off and sneak him a Hershey’s chocolate bar and a caffeine free Diet Pepsi. I came to the nursing home to get a picture with him in my prom dress every year. I met his friends and his family and knew them all by name. I learned the true meaning of friendship.
Jack lived for church every Sunday. He would tell me all about the service, who was there, who had skipped, who was baptized, and he would save me a program. He was lucky enough to have an excellent congregation who would drive him to church and back every Sunday. He always asked if I would go to church with him, I never did and to this day it is one of my biggest regrets.
When Jack was nearing the end of his life, I would stop to visit him more and more. When I moved to college I no longer worked at the facility that he lived in but I would still try to visit as often as I could. I would knock on the door and he’d say, “Is that my pink shoelaces?”without even opening his eyes.
In his final days, I was balancing 8 hour clinical days along with working on my weekends in the hospital and nursing school.
He passed away one cold February night. I was right there by his side. I came to sit with him between getting off work on first shift and heading to the nursing home to work third shift. I called his pastor in to be with us, I know he would have loved that. We prayed together and cried together. We were there when he took his last breath. I sat and waited with him until the funeral home came to get him.
A few days later, I received a call from his Pastor. She said that he requested not to have a funeral. I was devastated, I needed the closure but knowing Jack, I knew that he didn’t think anyone would come. Even though it was obvious to everyone around him what an incredible friend he was, Jack never thought too much of himself. He was privately buried in his home town.
A few months later, I received a call from his Pastor again, she wanted to dedicate a Sunday service to Jack. I was thrilled and I volunteered to lead the congregation in song, Jack’s favorite, “The old Rugged Cross.”
I arrived to the church service with Craig, we found a seat towards the middle of the congregation. It’s always awkward going to a new church, I always feel like I’m sitting in someone’s pew. It was obvious that we were newcomers, at least 15 families introduced themselves to us by the first hymn. I told them we were just visiting.
As the church service began, the pastor who I had met as Jack was passing, said that we had a very important guest in the congregation. I looked around trying to see who it was when she said, “Our dear friend Jack spoke very highly of her and she agreed to join us in honor of his memory. Some of you might know her as pink shoelaces.”
I had no idea Jack talked to the other members of his congregation about me. The congregation all nodded in agreement and smiled at me. I began crying. I had no idea how much I had meant to Jack until now. I was a blubbering mess the entire service yet I proudly led the congregation in song. I felt such a wave of relief and happiness and sadness all at once, it was hard to comprehend. I’m still crying as I write about it.
The congregation met for coffee after the service where we all spoke about our fond memories with Jack, and one of the ladies presented me with some flowers that were used as centerpieces to take home.
I had known this room of people for less than an hour and they were already treating me like family. No wonder Jack loved it here so much.
So, in honor of a very dear friend of mine who is no longer with us today, I dedicate this blog.
I also dedicate this blog to the nurses and CNA’s who proudly bear their pink shoelaces every day, by going above and beyond the extra mile for their patients and residents.