Med Errors and reality

[1mg.epi]

I almost had a med error of all errors. < 2 wks out of nursing school. I was a know it all new grad with a bad attitude. (smart ass).

I started a hep lock and drew up some ns from a bottle in the I.V. tray. I started to attach the syringe to the hep lock. Just happened I noticed off to the side the bottle I drew up the NS. It was not NS But KCL. Back then the bottles looked alike and we kept stock bottles of KCL in the ER. I dropped the syringe and almost vomited. I was shaking and told the patient, "oops, got to get another syringe." I have not had a med error since then, that I know of.

[nursinghumor]

The scary part of it is that the majority of medication errors probably go unnoticed, by both the nurses administering the medication or the patient receiving it.

As fast as we have to move these days, it is difficult to catch everything when so much of it doesn't have to deal with us personally.

The physician orders the wrong medicine (but at the right dose), the pharmacy sends up the wrong medication (labelled as the right drug ordered), etc.

Makes it downright scary to be a patient these days.

Andrew Lopez, RN
http://www.nursinghumor.com

[Judyd]

I have been using the laptop scan the med and pt system for about 6 months now. We still have the pyxis but the stinger cart scanner checks each barcoded med pre pt being given. I still remain totally amazed at how many times I find myself going back to the pyxis to correct myself. I truely believe I am and always have been a careful nurse. This system has proven itself to me for greater pt safety.

[3435]

Hi, everyone!! I am new to this forum. But I must comment on this issue. The hospital I work in just were inserviced on new pumps, Outlook from BBraun. Well, it has the bar coding and automated programming. I cannot say how much I love these new pumps. We are all so busy and these pumps really help me. I work in a critical care setting and are often hanging numerous IV bags in a day. Have any of you all worked with this system?

[nursinghumor]

National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP):"Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. A significant portion of those deaths is due to medication errors. That's more than die from motor vehicle accidents, breast cancer, or AIDS- three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems."
http://www.nccmerp.org/consumerInfo.html


Not exactly comforting statistics.

Andrew Lopez, RN
http://www.4nursing.com

[jzahn]

Has anyone ever seen a study on med errors and who is making them? If you look close you will see that most med arrors are done by the ever so educated RN.Look at the stats.

[cassioo]

maybe those RN's are giving the majority of the meds?

[nursinghumor]

[ QUOTE ]
jzahn said:
Has anyone ever seen a study on med errors and who is making them? If you look close you will see that most med arrors are done by the ever so educated RN.Look at the stats.

[/ QUOTE ]

Care to share the source of the statistics you're referring to? Otherwise it sounds like you've got an ax to grind rather than making an objective point. While you're at it, you didn't happen to mention your own licensure or education.

LPNs/LVNs, RNs, NPs, Pharmacists, MDs, etc all make errors. Sorry, don't think licensure or education has a damn thing to do with it.

Andrew Lopez, RN, ADN
http://www.4nursing.com

[cassioo]

I bet more RN's on my unit do make the most errors but then it comes down to numbers if everyone makes 1 error say: We have on a day shift
1 Pharmicist
1 LPN
7 docs (if they are all there or 3 that make rounds for their group)
5 RN's

As a unit
4 LPN's
38 RN's (2 with BSN one being me)
7 docs
3 pharmicists
3 secretaries
so the precentage is there like Andrew said everyone can make a mistake.

[1mg.epi]

We use the Pixis machine. Well I have seen it stocked incorrectly. Even in the narcotics bins. I have seen where the Doctor read a home med list wrong, and wrote an order to continue that med. We scan our orders into the computer for pharmacy. Take the Dr. s poor hand writing and the poor quality scanner, there have been errors. SO Why is most errors created by NURSES.

1st Here at my hospital they do not say who is to blame instead we say, "How can we do better." Pointing fingers and making judgment calls without scientific backing or study creates more problems, including social problems on the unit.

I agree with Andrew, jzhan has a problem with the letters R.N.