November 19, 2016

I Messed Up, Now What? (Overcoming Medication Errors)


There will be moments in your nursing career when you mess up. Either you will forget to do something or perform a task that is inaccurate or inappropriate. Learning is a process. When you enter a new profession, you should understand that mistakes can occur. We don't want to make mistakes, but the possibility is there. We are human. We make assumptions, jump to conclusions, get distracted, and omit things. With that said, nurses must understand that mistakes are opportunities to learn and not just from adverse events. You will not grow as a professional if you do not learn and follow-up when errors occur. I made mistakes and will never forget them. It was a medication error and it happened when I was only two weeks into my training as a graduate nurse. During that time, scanning medications wasn't a thing. You pulled the drug, read the label, did the five rights, and that was it. I was scheduled to give morphine IR (immediate release) but pulled morphine SR (sustained release) instead. Both options were available, but morphine SR was on PRN status and not to be administered during that time frame. I gave the medication and while the patient was taking it, I noticed both forms (IR and SR) were on the medication administration record (MAR). As soon as I saw both were options, I knew I had messed up. I went to my laptop, fished the drug label from the trash, reviewed both and confirmed I had indeed messed up. I gave the wrong medication!

I immediately went to my preceptor and explained the situation. She then directed me to the charge nurse station where I again, explained what had just occurred. I expected the charge nurse to yell and scream, but instead she said, "What you do next will determine what type of nurse you really are." She then explained to me who needed to know what and when. I went into my patient's room's (with management) and explained the medication error. I apologized a million times, and afterward, I cried in the bathroom. My preceptor and I then had a lengthy conversation about what processes went wrong and what my role as a caregiver will now involve. The morphine SR could lead to respiratory depression or change in mental status. I then called the physician and explained the error. I completed a medication error form, contacted the unit manager, and explained what happened once again. Each party needed notification, explanation, and clarification. During all of this, I stayed in the patient's room collecting vital signs every 15 minutes for two full hours. I wanted to make sure my patient was safe. If an adverse event took place, I wanted to know as soon as possible. It was my fault. If my patient's blood pressure or respiratory rate was going to drop, I would be there to intervene and take control of my mistake.

I had made a mistake, but the priority was the patient, not my ego. I didn't care how bad it looked or sounded. I wanted the patient to know I still cared and wanted what was best for him. At first, he called me an "idiot" for making the mistake. I allowed him to express his anger due to the fact that he would be experiencing the ramifications of my actions. An hour into the 15-minute assessments, he then said, "Thank you for monitoring me. I appreciate your dedication to fixing this error and making sure I'm okay." By the end of the two-hour window, I felt I had regained some of his trust back. The patient was okay, and I notified the appropriate parties and documented the needed details. Trust is a funny thing. It takes hours to build and seconds to lose. When I knew I had messed up, I originally wanted to run away and never see the patient again. I was ashamed and embarrassed. I wanted my preceptor to take charge, fix it, and I not to be involved in his care anymore. But you don't learn from messing up and hiding. You won't learn the "why" or how to repair the process if you're not involved with the care from beginning to end. Screaming and yelling don't teach. It takes a true professional to have patience and understand how important it is to allow someone to stand tall during their mistake.

Mistakes shouldn't be something you hope for. Mistakes shouldn't happen. Patients shouldn't have to experience the consequences of your learning experience. But sadly, they do. Most of the training in the nursing profession is done on-the-job. Clinicals and practicums will only teach you so much. There will be a point where you must hit the ground running and learn while you are caring for folks. If you don't learn from your mistakes, there will be more mistakes, and the future outcomes could be deadly. Embrace these embarrassing moments, tell the appropriate parties (including the patient), and you will grow professionally. When my grandfather received an inappropriate dose of insulin when he was admitted to the hospital (which caused a hypoglycemic event), I told his nurse this very thing. When my father received his entire day's worth of medications all at once (which caused profound hypotension), I wish I was there to tell his nurse the same thing. We can't change what has already occurred. What we can do is learn from these experiences.