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My Response to Med Error Stories on Lippincott Forum:
I am embarrassed to admit; in my 30 yrs of nursing, I had 3.
None of the 3 was detrimental; and they were lessons
1. (As a very new nurse) Gave 4 units of Aspart insulin ordered "give with meals" to a patient before verifying if/what the patient ate. The patient did not eat. Dropped to 40's symptomatic. Recovery fast after giving OJ. Didn't know the patient. Lesson learned-verify intake of meals first. Know your patients (ask questions of unfamiliar patients). Wait until you see what they ate.
2. (10 yrs. experience) Hurrying through a med pass, to be done on time. CNA gave me VS for the morning. I used these values (142/74) to give Lopresser 50mg. Patient bottomed out 80/30. Sent to ICU for treatment. Lesson learned-do your own VS. Re-check after giving the drug. Slow down, may be better to be late than risking safety.
3. (Recent. 30 yrs. or more experience). Order reads: "Oxycontin 5mg. Give 2 tabs, PO Q4 hrs. PRN pain." Nurses punched out the 2 tabs from one bubble of the blister pack, to administer the dose. End result, patient receives 20 mg every 4 hrs. PRN pain. The error was not found until a nurse questioned a second delivery of a blister pack, only contained one pill per bubble and the patient had a change of condition. The pharmacy made a mistake and filled the previous blister pack with 10mg not 5mg. Lesson learned-pharmacy staff can make mistakes too. Always question something that looks different, (author of the order and dispenser of the medication). Trust your gut. Check the medication to verify correct medication and dose printed on the pill.
8/8/2018 11:35:26 AM