So, you just made a medication error…

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.

RaDonda Vaught – a Tennessee nurse who was tried for reckless homicide for administering vecuronim – a paralytic agent instead of versed – a sedative resulting in the patient’s eventual death at Vanderbilt University Medical Center.
While her mistake was fatal, she was NOT the only one at fault.

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.


1 Comment

  1. Lori
    October 7, 2019 / 12:14 am

    You are so brave. You know I’ve never heard of a nurse admitting to a mistake before. And like you said, they do happen.

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