Of Med Errors and Brain Farts

I read the physician’s order carefully, looked up the medication in the nurses’ drug book, and consulted with our pharmacist before I gave it.  While signing the medication administration record (MAR), I read the order again, and I did not see the same dose I had read the first time.

Immediately the blood in my feet rushed up to my ears and I was lost in pounding waves of white noise. Fuck, fuck, fuck, I made a med error, and it’s a serious one. Of course, I didn’t say these words out loud. Instead, I carried the patient’s chart and the empty, pre-filled syringe to the nurses’ station. Putting them in front of the charge nurse I said, “I think I just made a med error, a bad one. Look at the order and the syringe label. Tell me what I’ve done.” She stopped what she was doing. She read the order and examined the syringe. “You gave the right dose. You didn’t make a med error. Now breathe.” The pounding breakers of white noise in my ears subsided into the gentle lapping of my breathing. Another nurse came to my side saying, “I know exactly what you’re feeling.”

I felt relief. My patient was safe. It was a medication I am not very familiar with. That’s why I read the order carefully, looked it up, and consulted with our pharmacist. All I can determine about my confusion after giving the dose is that I had a brain fart. Somehow my eyes and my brain disconnected after I gave the medication, and the order unexplainably failed to make sense. That’s the best I can come up with: a brain fart.

Later, my coworkers told me their stories of making med errors. We all make them. I didn’t know that when I was a new grad.

It is unbelievable to me as I type this, but it is true: in nursing school  I had an instructor who told our class that she had never in her thirty year career, ever made a medication error. Never. And I was young, and shiny, and idealistic enough to believe her. Seriously, I did. So when I made a medication error during the first couple months of my new-grad job, I was sure that I was not cut out for nursing. At that time, my coworkers didn’t gather around offering support like they did recently. No, I was written up, and had to call the pediatrician and tell him that I had forgotten to hang a dose of ampicillin. He was more sympathetic than the day shift charge nurse back then. I made other medication errors too, nothing serious, but enough to consider quitting nursing during my first six months of practice.

Then I met one of the best nurses I have had the pleasure to work with. For some reason, she decided to mentor me. I confided to her that I considered quitting nursing, because I made med errors, and that my instructor never had.  She laughed.”If that instructor of yours never made a med error, then I’m thinking she’s too dumb to catch them. You are so crazy. Let me tell you about med errors…” She was a great nurse, not a perfect one.

She showed me how to string nursing tasks together like a pearl necklace, and eventually I gained the confidence needed to stay in nursing these past twenty-four years. I still make mistakes from time to time. I take responsibility for them. I learn from them. I am compassionate towards my coworkers when it happens to them. Nursing is not a risk-free profession.

And sometimes I have brain farts.

8 thoughts on “Of Med Errors and Brain Farts

  1. I remember my most serious med error; and I remember feeling the blood drain from my body. I had a kind charge nurse, and even though I reported it, they didn’t put it on my record. No harm came to the patient, but it sure changed the way I did things!

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  3. I’ll never forget, as a new grad, the well-respected charge RN telling me how, when she was green, made a med error. She passed all of patient A’s morning meds to patient B! I couldn’t believe it, but it made me feel a lot better that someone so smart and capable wasn’t perfect. And that everything turned out ok.

    I’ve made my share of stupid med errors (like forgetting to open the roller clamp on that IV piggyback). I’ll never forget the first time I made a serious error, with a patient on CRRT. I was ready to drop everything and go make a job application at Starbucks. That patient ended up fine, but holy hell that sobered me up.

  4. Thank you for this post. I made a med error this week, that could have had very serious consequenses to my patient. I have been a nurse for over 5 years and have been beating myself up for this. Knowing that I am not alone is a huge comfort to me, just a gentle reminder to slow down. Thank you again!!

  5. You’re welcome, and thank you for your comment. All we can do is learn from our mistakes and move forward. You are most certainly not alone. JP

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