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Ihave a confession. Recently in my work as a staff nurse, I made a medication error. A medication was ordered for 1730 (5:30 p.m.) and documented on the Medication Administration Record (MAR), and I missed it. The medication had been given earlier in the day and the initials of the nurse before me obscured the listing for the 1730 dose. I discovered the error around 2015 (8:15 p.m.) when I was looking at the HS bedtime meds I was to give.

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I was horrified. As the realization set in that I couldn't "legally" give the medication and not consider it late, a sinking panicky feeling arose in my gut. I began to rationalize in my head all the reasons why this happened: It was an unusual time to give this medication. "1730" was not the typical time for BID dosing. The nurse on days should have written smaller so the time for the second dose would have been more visible. We were busy at shift change and I didn't have enough time to thoroughlyexamine my MARS. The error wasn't life threatening and would not change patient outcome. So the reasoning went in my head as I tried to justify why I hadn't given the med at the right time.


I went to give the patient the medication and she said, "I'm supposed to take this with dinner. Why didn't you give it to me then?" Ouch!! She noticed. More than that, she was worried and said, "This will mess me up, won't it?" I tried to reassure her, telling her how the medication worked and why we gave it twice a day. I explained I had missed the time, apologized, and said I would follow up and make sure she was okay.


What became most disturbing about this situation was my reaction. The truth is I was trying to justify the error and wrestling with myself about reporting it. Everyone makes mistakes and this could happen to anyone. But it happened to me. It's easy to think about the mistakes of others as understandable and forgivable. Furthermore, writing up incident reports when mistakes are made isn't about pointing the finger at someone. Incident reports are supposed to help us discover and fix system problems. But I didn't want anyone to know I had made a mistake. I work hard to be conscientious, to be a mistake-less nurse.


In a split second I realized I had a choice to make. I could give the medication and not tell anyone. Or, I could do the right thing and notify the charge nurse and the patient's physician, then write up an incident report, and give it to the house leader.


Proverbs 28:13 (NIV) says, "He who conceals his sins does not prosper, but whoever confesses and renounces them finds mercy." Verse 14 adds, "Blessed is the man who always fears the LORD, but he who hardens his heart falls into trouble." Although there wasn't anything inherently "sinful" in not giving a medication at the correct time, there was great potential for sin in my response. I could hide or I could admit my error. As I struggled with pride and embarrassment, I knew I had to act quickly as one who always fears the Lord. I paged the physician, reported to the charge nurse, and wrote up and turned in an incident report.


1 John 1:5-10 tells us to walk in the light as Jesus is in the light. We are to walk in the same light he walked in, to work at living righteously in every action, every thought, every day. We are to embrace what light represents-all that is good, true, and holy; and abhor the darkness of what is evil and false. Rather than being sinless, we are told to admit our sin (vs. 8, 10). When we confess our sins, he is faithful, just, forgives us, and purifies us from all unrighteousness (v. 9). As God makes us righteous, we live in fellowship with him and others.


Of course, it was a great relief to admit my mistake. I reported back to the patient that her physician said giving the medication late was okay and not to worry. Admitting the error also became an opportunity to walk in the light in front of others because no one expected me to "write up" the incident.


Once again God's Word proves true. I confessed and renounced my mistake and found mercy and enhanced relationship with God and with my colleagues.-KSS