End of Shift: Medication Error Teaches Lessons

By | 2022-02-11T11:08:16-05:00 August 25th, 2009|0 Comments

It’s every nurse’s nightmare. By missing a decimal point, by not carefully checking my math, I overdosed a pediatric patient by 10 times his prescription.

Thankfully, the child suffered no permanent damage as a result of the overdose. But in the fallout, I considered leaving my unit and taking another position in the hospital as I found the entire process humiliating. But in the end, I stuck it out and learned a valuable lesson.

A Recipe for Disaster
I have been a nurse for 28 years, nearly all of them spent at the bedside. I work in a six-bed pediatric ICU in a hospital known for serving the needs of medically underserved, mostly minority, patients. Our specialty is trauma care.

The error happened the night before Thanksgiving. I had recently changed my hours from eight to 12-hour shifts and from evenings to day/night rotation. I worked Saturday night, then a 12-hour day Monday. My husband had been recently diagnosed with cancer and we met with the oncologist Tuesday to discuss treatment options. I napped poorly Wednesday before I came to work that evening. I had come in for a meeting that morning to discuss complications with this same patient’s intubation that occurred Saturday night. I felt I had failed the patient during his intubation and was anxious to prove I was competent to care for him.

Unfortunately, I was in no condition to care for such a critically ill child.

I remember the nurse who gave me report stating that his pain was not well controlled and that his heart rate and blood pressure had recently spiked. He was 9 liters fluid positive and was on a Lasix drip. He also was on dopamine, fentanyl, and Versed drips. I was focused on his pain management. I remember doing a quick physical assessment and checking his lines and drip rates. I thought that the Lasix was a 1:1 drip and it was running at 4cc per hour. The Lasix was a 10:1 drip, and I ran it at 10 times the normal dose over 12 hours.

To make matters worse, I hung a new bag of Lasix at 5 a.m., and though I checked the bag with another nurse, I still did not pick up my error. The 7 a.m. nurse called me when I got home after she noticed the error.

Lessons Learned
So what have I learned from the mandatory staff meetings, root cause analysis, and subsequent one-day suspension and letter in my personnel file documenting the policies that I violated? How has my practice changed so that I will never again make the same error?

We now have a policy in place that we must verify one another’s medication drips against the med orders as a part of change of shift report, and document the nurse’s name on the computerized medication record. My experience has been that not all of my peers want to do such a bedside check but will do so when I request it.

I cannot say I will never again commit such an error as I am human. I am more aware of how outside factors affect my nursing practice and am more willing to give up the sickest patient if I am tired or distracted. No matter how busy it is, I now am less reticent to ask colleagues for help, especially in checking any IV medications that I am to give or to check calculations.

I do not agree with the suspension that I received. Our profession relies on honestly reporting errors because there is often no other way to discover an error. When I was a new nurse I was assured that a med error was not something that would lead to punishment. When confronted with my concerns about the suspension, my director of nursing told me it was to ensure I realized the gravity of my error so it wouldn’t happen again. I replied that nothing external could compare with what I had put myself through with guilty feelings, sleepless nights, reliving that shift over and over — PTSD-like symptoms.

I am no longer angry about the way my institution handled the error and am focused on how to improve my practice and work with my colleagues to ensure the safest possible environment for our patients.

Editor’s note: Author’s name withheld.

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