Of Med Errors and Brain Farts

 

Giving an Unfamiliar Medication

I read the physician’s order carefully, looked up the medication in the nurses’ drug book, and consulted with a pharmacist before I gave it. Afterward, 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.

Accountability for My Actions

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.

Relief: The Patient was Safe

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 an unfamiliar medication. That’s why I read the order carefully, looked it up, and consulted with the pharmacist. The only explaination I have for my confusion after giving the dose is that I had a brain fart. Somehow my eyes and my brain disconnected after giving the medication, and the order unexplainably failed to make sense. That’s the best I can come up with: a brain fart.

Everyone Makes Mistakes

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 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.

Nurses Supporting Nurses

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.

Eventually I gained the confidence needed to stay in nursing these past thirty-three 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.

This post was originally published on January 30,  2011. I feel reposting it may be beneficial for nurses new to my blog. It has been updated.