My first med error....

[Tessalon]

Advertisement - Members don't see this ad

So today was not a good day at work for me. I was informed that I missed and sent out an inappropriate antibiotic dose for a patient in renal failure yesterday evening. I just graduated in May and I am working in a hospital, and I guess I can say this is my first error where I have blatantly overlooked something like this. The patient is okay, but from my understanding, the resident who prescribed it (on the nephrology service) got a pretty good chewing from his attending today, and I really can't help but feel pretty depressed about it. Does anyone have an experience to share about med errors you have seen or missed? I know I'm not alone in this (and I have definitely learned to watch for the same mistake again), but it feels pretty sucky.🙁

 

[no-see-um]

You're not alone in this. We all make mistakes. It's sad that the resident got 'chewed out' for that, because the real way to fix errors is to fix the system. Scolding someone for making a mistake is not a real fix. Teaching them, and conveying the importance of what is being taught could be done in a professional manner.

Everyone's going to make a mistake. The real question is, "what are you doing to correct it?"

Feel better and good luck.

 

[WVUPharm2007]

Once I stocked the neonate pyxis with adult strength vitamin k vials rather than the neonate strength vials. Several neonates got an overdose. The pharmacist who signed off on the drug/dose lost a lot of sleep over it. Me not so much...it happened, nobody got hurt...I just forgot about it. Having a short memory is probably the best plan...ain't nothing going to change it. Make sure you don't do it again, but don't dwell on it. **** happens....

 

[konkan]

So today was not a good day at work for me. I was informed that I missed and sent out an inappropriate antibiotic dose for a patient in renal failure yesterday evening. I just graduated in May and I am working in a hospital, and I guess I can say this is my first error where I have blatantly overlooked something like this. The patient is okay, but from my understanding, the resident who prescribed it (on the nephrology service) got a pretty good chewing from his attending today, and I really can't help but feel pretty depressed about it. Does anyone have an experience to share about med errors you have seen or missed? I know I'm not alone in this (and I have definitely learned to watch for the same mistake again), but it feels pretty sucky.🙁

I hear you. I am an intern at a hospital, and on my first day on my own (first post-training shift), I mixed up two IV meds (made Meropenem instead of Pantoprazole). The pharmacist caught my mistake, but I still felt bad for a while.

 

[sdn1977]

Tess - you know I've made plenty of errors - you've read enough of my posts to know them.

I'm not surprised the resident got chewed out. I'm assuming you're referring to a medical resident. They need to function as if there is no double check - that's their job and medicine has a different "culture" than we do. As a resident, that person has had years of rf dosing, particularly if its a nephrology resident!

We are the double check & you missed it. Good job owning up to it. Now, the hard part is to figure out why it happened to you. That's always the key lesson in any error - figuring out why it occurred. I can guess - your mind is occupied with other stuff (pyxis perhaps?), fatigue, distraction... You may not be able to identify the factors while you're still emotionally tied to the fact you made a significant error.

Let yourself be depressed today. It will help you (at least it did me) to follow the patient closely so you can know how much the dose error affected the physiology or morbidity of the pt. It will also help to have someone to talk to - you have an advantage of having an SO that knows the business - so talk about it. Did you write up an incident report? I hope so - thats a way to methodically put down what exactly happened & its important for a variety of reasons.

In my institution, we developed a quarterly departmental M&M meeting to discuss our errors. We found that learning from each other helped us to prevent the factors which cause the errors.

Altho you won't make this same mistake, you will make another. It happens. Do what you can to heal yourself & go back tomorrow & start fresh.

Good luck!

 

[Epic]

Don't worry about it.

It's a med error and it happens. And no harm done to the patient.

Consider it as an educational opportunity since you'll learn a great deal from it. But for something like this, I will call this medication error a systems error. Your pharmacy system should have flagged this patient when you inputted an antibiotic by cross referencing the renal function. In fact, every renally excreted drug should be linked to the lab data and CrCl.

Many times, it's a simple process in your Pharmacy operating system to program a trigger to catch this sort of error.

Report this to your MERT Committee... (Medication Error Review Committee) which should be an adhoc committee to P&T.

 

[SpirivaSunrise]

Tess - you know I've made plenty of errors - you've read enough of my posts to know them.

I'm not surprised the resident got chewed out. I'm assuming you're referring to a medical resident. They need to function as if there is no double check - that's their job and medicine has a different "culture" than we do. As a resident, that person has had years of rf dosing, particularly if its a nephrology resident!

We are the double check & you missed it. Good job owning up to it. Now, the hard part is to figure out why it happened to you. That's always the key lesson in any error - figuring out why it occurred. I can guess - your mind is occupied with other stuff (pyxis perhaps?), fatigue, distraction... You may not be able to identify the factors while you're still emotionally tied to the fact you made a significant error.

Let yourself be depressed today. It will help you (at least it did me) to follow the patient closely so you can know how much the dose error affected the physiology or morbidity of the pt. It will also help to have someone to talk to - you have an advantage of having an SO that knows the business - so talk about it. Did you write up an incident report? I hope so - thats a way to methodically put down what exactly happened & its important for a variety of reasons.

In my institution, we developed a quarterly departmental M&M meeting to discuss our errors. We found that learning from each other helped us to prevent the factors which cause the errors.

Altho you won't make this same mistake, you will make another. It happens. Do what you can to heal yourself & go back tomorrow & start fresh.

Good luck!

Oh, I think you may be confusing our two cough members? (Tessalon & Tussionex)

Not that it makes a big difference as far as the advice goes though 😉

 

[tussionex]

tussionex is confused....
but, yes...it's still good advice!

 

[rxforlife2004]

tussionex is confused....
but, yes...it's still good advice!

I am a new grad too and working in a big hospital also...kinda scary sometimes, especially dealing with peds population. I am still very inexperienced with this.....anyway, sorry to hear your story, but just learn, that's the only way we get better everyday. Glad that no harm done to pt.