The Medication Error

Before I had even gotten my feet underneath me as a new nurse, I lost my footing. I made a medication error.

I was a brand new RN fresh off orientation on an orthopedic unit in acute care. I rounded with Dr. G on his patients, 2 elderly ladies in a semi-private room. Note- the same semi-private room.

Dr. G barked out an order in my direction “Change that D51/2 NS to D5W on Bed A.” (apologies for referring to patients by their bed assignment, but that’s how it happened). At least that’s what I thought I heard Dr. G bark, I mean, say.

Eager to be efficient, and before Dr. G had even returned to the nurses station, I had the D5W in hand, ran in, took down the bag that was hanging, labeled, spiked and hung the IV. On Bed A. An expedient medical intervention by a skilled medical professional, Yours Truly.

I was proud of myself.

I was so wrong.

The Repercussion

Later that day, my Nurse Manager called me aside. “I need to see you. In my office. Now. ” That was enough to cause me anxiety. I had a sick feeling in the pit of my stomach. I followed her into her office. She seated herself in her chair behind her desk, and motioned for me to sit across from her. Immediately I noticed there was nothing on her gleaming wooden desktop except for a single piece of paper.

Without further ado, she informed me that I had administered the IV fluid to the wrong patient, which constituted 2 med errors. Apparently Dr. G’s orders read “Change the IV fluid on (Bed B) to D5W.” Oh. So both patients had the wrong IV fluid. The blood drained from my face.

In addition, and most important, I had not identified the patient. She proceeded to inform me that I was on three days suspension without pay, and to clock out immediately. She pushed the disciplinary form across the desktop towards me for my signature.

As busy and short-staffed as the unit was, my mistake was clearly exceedingly grave, as I was being sent home mid-shift and was Banished from Patient Care for three days. I wasn’t indispensable after all. Because I was Unsafe. I gathered my things and walked the Walk of Shame in front of my peers to the elevator. Drove home in the early afternoon on empty streets without traffic. Home to an empty house in the middle of my workday.

How Could This Happen

We all know the 5 (6, 7, 8 and climbing) Rights of Medication Administration:

Right Patient

Right Drug

Right Dose

Right Route

Right Time

So what had happened? How had I failed in something so fundamental? There are many things that contributed to my error. I will identify three that I was responsible for:

I opted for speed over process and safety. I took a shortcut by failing to check the written orders, note them, and identify the patient. Following the same process step by step without variance prevents errors. Like an airplane pilot. I learned an invaluable lesson well that day. BE THE PILOT. Ego. Pride. I was eager to please and perform. To show everyone, esp. Dr. G, what a bright new RN I was. Because surely Dr. G was going to be impressed by how fast I could make his orders happen. Looking back, I’m pretty sure he was only vaguely aware of my presence at all, and the only thing that might have caught his attention was if I had hung that IV wearing a tutu while whistling Dixie. Unintentional learning- maybe the most interesting. I had been an LVN before becoming an RN. At the facility where I worked, LVNs did not manage IV fluids. So oftentimes I would be in the room and watch the RNs hanging IV fluids.

I admired their physical grace and coordination while nonchalantly flipping IV bags upside down, backfilling, spiking, reaching to hang….and I so wanted to be one of them! A bona fide RN with IV hanging privileges. But never in those scenarios I witnessed did the RNs ever check armbands for IVs. So the unconscious learning that took place…and that was indelibly imprinted…was that IV fluids are not medications! Crazy, huh? But that learning was exactly what happened…unintentionally.

Of course, in nursing school, there must have been that day where they said “IVs are Medications” Did I miss that day? Was I only studying to the tests, and not the real world? I don’t recall. There’s school learning and then there’s real learning. How real learning takes place is another blog. As I’m an Educator and all.

How I Felt

Shock soon turned to utter devastation. I was on the crazy train. I felt shame, embarrassment. Confusion. I had always been the straight A student. Class President. Honor student. Failure and suspension were not me. I was one of the top RNs in my class. That person. Now who was I? It was ego shattering. My self-confidence vanished. Gone. Just like that.

Once home, isolated and alone, my thoughts collided. Were the patients harmed? Would I be fired? Was I forever marked? How could I ever practice nursing again? My emotions reeled. I pictured another RN going in to my patients’ room and fixing my error. Hanging the right IVs.

Making the mistake was one thing, but being suspended added gravity and shame. This was a felony, not a misdemeanor. I wasn’t angry about the harsh punishment. They must be right. I was sick and humiliated. Alone, I curled up and cried, but there was only an hour before my kids would be home from school, and I had to put on my Mom face. Dinner had to be made, homework had to be checked.

Fortunately, the patients did not suffer any ill effects, but that was only luck, right? If I could do what I had done, I could make an even worse mistake, right? I could hurt someone. RNs aren’t supposed to hurt people.

Added on was that I was a single Mom of three, and three days without pay was going to hurt. Although I’m sure that was the intent. The rationale being that if the punishment hurt enough, the lesson would be learned.

And finally… I wondered if I should even be an RN. Hadn’t I just proved that I shouldn’t? Which was confusing, a cognitive dissonance. I had spent 6 years studying to be an RN with unswerving determination and… I shouldn’t be an RN?

My world did not make sense.

Recovery

I didn’t need suspension. What I needed was counseling and support. Here’s what MeNow would say to MeThen:

“Give yourself time, Beth. Time brings perspective, trust me. You don’t know this yet, but every, and I mean every, RN makes mistakes. Welcome to the real world. Reality check- you are not perfect. You also don’t know that you are going to be a gifted nurse. And go on to help alot of people. Figure out what went wrong and learn from your mistake. Find someone safe to talk to. Forgive yourself.”

And also from future Me: “Have a glass of wine. You don’t know this yet, but a robust Cabarnet is going to be your favorite.”

I returned to work. From then on, I was an absolute freak about patient identification. Even if I was in the middle of a med pass, and turned around to grab a unit dose container of Milk of Magnesia out of the patient’s drawer, and walked back to the bed…I re-checked the pt’s ID. (This was before bar coding).

Time passed, and my shaky self-esteem began to stabilize. Eventually the good days outweighed that one awful day, and my mistake was finally in the rear view mirror.

Was that my last medication error? Well, as any nurse knows, that’s a rhetorical question. No, it wasn’t. Making mistakes never got easier, but recovery happened faster. My ego was shattered, but when it came back together, I was more resilient. Healthier.

How did mistakes change you? How did you recover? I’d love to hear your feedback.

Here’s some more articles you might enjoy:

Thank You, Nurse Anita, for Taking Care of my Mother at the End

Uncensored Thoughts of a Nurse Interviewer

10 Rookie Mistakes to Avoid

Until next time friend,

Nurse Beth