Nurses worry about medication errors and system failures

“Been in the field for about 5 years (assistant turned RVT) and last week I made a mistake involving drug calculation and administered the wrong amount. Patient was fine by the end of the day but the procedure had to be postponed. Owner was very understanding and amazing about it but I cried at work and have been beating myself up about it ever since. Please share your f ups so I feel less shitty 😭 submitted by /u/Available-Clock8006 [link] [comments]”

“PLEASE stop calling yourself stupid, and grant yourself some grace. We have all made med errors. You did all the right follow up actions. Use any errors as a learning and growth experience. It is very overwhelming in the beginning. Hang in there! [re: I made a huge med error and now I’m cooked]”

“Longest story short - admitted a family around midnight, child was hooked up to fluids and came from ER. Pump and fluids included. - I scanned the bag, checked the rate, etc, and frequently checked the IV site due to issues that happened in the ED throughout the day. - came back next night to hear parents and day shift said the pump was off the entire night and unsure how long he didn’t get his fluids. child was NPO for emergency procedure next day -it was reported that they were unsure how long”

“I've literally done this today, and now I'm trying to cope by being on Reddit lol. Pt was prescribed Oromorph 1.25 ml. I gave this correct dose. Then, 10 mins later, me and my nurse come round with the controlled drugs (1.25 oxycodone). My nurse is in the bay with me and tells me to give it to bed 6, and I turn and give it to bloody bed 7. I immediately realise what I've done. I start shaking and crying and tell my nurse immediately. The ward sister makes me write a drug error reflec”

“Shouldn’t the pharmacy have changed the vanco orders/dosing? [re: Why have you reported another nurse?]”

“If it’s easy and I have time, I’ll pass it. It just depends. Yesterday had a 1900 med that was linked with 4 other meds in a timing sequence. So no of course I didn’t start that one. Use your discretion and be able to back it up. If night shift can’t be understanding when you couldn’t get to something, that’s their problem. [re: Vent/Discussion Request: Do You (Night Shift) Give 0700 Meds? Do You (Day Shift) Give 1900 Meds?]”

“Hello, this is my first med error so I am a bit nervous. I am a float and was called by the patient's nurse today to inform me that the med was not charted or not given as a heads up so I can make the incident report myself (very nice of them) I am going to do an incident report myself when I am back at work as I cannot access that at home. The medication was metformin. I didn't see that the patient had this medication at this time and did not write it down on my morning "cheat shee”

“And also. Learn from this. Your med pass is your med pass. Don't let another nurse intervene mid pass. If they start let them finish and visa versa [re: I made my first medication error as a nursing student, and I feel awful.]”

“Effed that other nurse. They will believe them over you. THEY have the med to patient B4 your FINAL check. I had a preceptor do that to me. Trying to halt my med checks and she made a mistake. One with administering the med (it wasn't a control med) and the other whole pulling meds. She closed the flap on the pixis Soo quickly I thought I pulled the med since it was in the same draw as another med. The door opened twice signaling to grab the other med. For the rest of the day they wanted me”

“Hi everyone. I’m a nursing student on my second clinical rotation, and today I made my first medication error. I was assisting a nurse with medication administration. I scanned the patient’s wristband and medication and popped the tablet into a medication cup as instructed. The nurse picked it up and administered it, but right as the patient was swallowing, she realized the dose was incorrect. It required the pill—carbidopa/levodopa- to be split. Instead of 0.5mg, 1mg was administered. Unfortuna”

“I heard this scene play in my head the moment I realized op was talking about Tylenol. [re: I made my first med error]”

“Most new grads don’t think to do that, especially for scheduled meds. That’s just one of those things that experience teaches us. [re: I made my first med error]”

“Completely agree. I would not disclose that you gave the wrong person the medication. An example I have used was giving a dose of Dilaudid IV, when it was ordered IM. This error did not cause any patient harm and was made as a new nurse who had never seen Dilaudid ordered IM (I have never seen it since, either). I reported it immediately, despite being completely mortified and (horrified) that I made a med error. When I reported the error to the physician (surgeon) he was really angry that I was”

“Remember that you can always escalate something if you don’t feel it’s right, even if an RN or Dr isn’t concerned [re: Did I screw up?]”

“I'm a mother baby nurse. It was my 3/3 over the weekend. Ive probably had a combined 6 hours of sleep over the last 3 days. Last night at my 6 am meds my patient had torodal ordered. Now I cannot remember if I pulled the correct med or if I scanned it. Its now been several hours since my shift ended, so if I did screw up I imagine they would've called me. But now I'm sitting her anxious that I fucked up. submitted by /u/MedicalWillow573 [link] [comments]”

“Taking meds from med supply tends to largely matter on the facility and how they store their meds. Diverting oral meds tends to happen more often in facilities like AFHs and SNFs because security measures to safeguard the meds and their counts tend to be more lacking than compared to hospitals where med diverting can get flagged extremely quickly. That’s why in the hospitals I’ve worked at, you can almost always find a bottle of Tylenol or ibuprofen in a drawer at most nurses stations.”

“So the other night a couple of nurses wanted to test their blood sugar on the glucometer. I signed in to it and let them have a go at it, they didn’t hit reject after and it accidentally sent the result. Now the hospital is emailing me and asking which patient the test was for. Am I going to get into serious trouble? I plan on ignoring the email because I put in my four weeks already. But still kind of freaking out. I know it was stupid so don’t guilt trip me. submitted by /u/Individ”

“Yea this is an important answer since the actual answer is going to depend on what pump and EMR you use. Since most folks use alaris and EPIC, the scanned/program volume is going to be what the ordered volume is, not any overfill. It will kick back to a KVO rate after the scanned volume finishes.”

“I never said I wasn’t accountable for my mistake. I’m fully aware that medication errors are serious, and I understand it was my fault. I was acknowledging in my post that lack of my preceptors support and supervision contributed to my situation and those are not excuses. I’m a new nurse, actually only my 5th shift ever, and I’m learning, I won’t be taking your advice of finding a new line of work lol, I hope you never make a mistake in your career. At the end of the day my patient survived and”

“1 mg of dilaudid, while not the dose prescribed, is still within the normal therapeutic dose range. It's not like you gave 100 mg.”

“It happened because of you rushing. You don't rapid push Dilaudid, give double the prescribed dose and expect no consequence. You don't make excuses that it's only your orientation because guess what you have a license.”

“Has anyone experienced something like this before? 😭 I accidentally gave 40 units of lispro instead of glargine . I know, stupid mistake. I feel terrible about it, and this has been a huge learning experience for me. The patient did become hypoglycemic afterward and needed treatment and close monitoring. Thankfully, the patient improved and was doing okay before I left. But by the end of my shift, their blood sugar had gone really high, 400+ , after being low earlier. I’ve actually been reading”

“No such thing as a dumb question. In 2024 TN changed from using a 3 drug concoction to a single drug, phenobarbitol. I dont understand why. It can't be cost because you can't tell me potassium is expensive.”

“So in the beginning she was standing with me as I was hanging the medication- I kept trying to start but was getting "air in the line" alert. She tried to redo it as well with the same alert. She had someone bring another pump. I programed it and she walked around the patient to the computer to start charting. I had the same error.. I didn't realize I hadn't even PRIMED the tubing (and she didnt either) I sheepishly told her my mistake. I primed the tubing and restarted the mac”

“This is wise advice. In reality taking the time to double and triple check is like less than 60 seconds. I also find it helpful to say it out loud in these situations. It helps you really think about the meds you’re giving and someone else could be listening and correct you. If it’s in the moment with verbal orders, definitely repeat it back as you’re giving the med. Ideally you’d have another nurse in this situation to take 20 seconds to verify it with you.”

“Well... I'm a big believer in narrating what I'm doing. As silly as that sounds, you will hear yourself saying that you are doing something dumb and stop it immediately. Nowadays lots of pumps automatically program, but in the olden days 🙃. This is ONE GRAM OF KEPPRA for my SEIZURE PATIENT, were gonna run ONE GRAM over FIFTEEN MINUTES. 400 MLS AN HOUR divides down to 100 MLS IN FIFTEEN MINUTES. RATE FOUR ZERO ZERO. VOLUME, ONE ZERO ZERO, UNCLAMP, START. NOT BEEPING, THE IV IS GOOD, KEPP”