Guest Author - Lorraine Hover
Every nurse makes a mistake at one point in time. We are only human! Due to the high risk of malpractice suits and adverse reactions to incorrect drugs the risk of a lawsuit are higher than ever. What can we learn from making such mistakes? What should we learn?
When I was a new nurse back in the mid-1980's I had just graduated and was in my first job as a "real" RN. Back in those days you could practice with a temporary RN license until your board results came in. Sitting for boards only took place twice a year and it could take eight to ten weeks to get your results. I had just gotten that brand new license and was eager to prove myself as a new nurse. I got over-confident in my skills and failed the first rule of giving medications - I forgot to follow the five rights.
My medication error was that I gave the medications to "Mr. Smith" when it should have been "Mr. Jones". I had pulled the medications from the slots (no fancy medication dispensing machines in those days). I looked at the room number and bed designation and went to what I assumed was the "B" bed. I had guessed wrong. At that hospital the "A" bed was always to the right and the "B" bed always to the left. I had assumed that "A" bed was next to the door all the time.
Let's look at what all I did wrong. I did not verify the patient using two forms of identification (remember one of those two forms should never be the room number and/or the bed designation). I simply pulled the medications and went to the room. I failed to check the arm band and I failed to even address the patient by name. "Mr. Jones" and "Mr. Smith" could both respond and would have if I had called them by the incorrect name. I made matters worse by not reporting the medication error to my charge nurse. I didn't want to admit that I had been wrong and could have been dead wrong (as in patient dying).
I learned that the five rights of medication administration must be followed with each and every medication you ever give in your entire career. By consistently following the five rights the likelihood of a medication error is reduced. I have yet to fail to use the five rights even 27 years later!
What factors increased my likelihood of a mistake? I had that "new RN" disease of over-confidence and the feeling of infallibility. I set aside the rules because now that I was an RN I knew it all. I was afraid to tell someone I had not lived up to my own unrealistic views of myself and my abilities. I did not even tell the patient or the patient's physician much less file an incident report.
What can you take from my mistake? I hope it reminds you that we nurses are human beings and we will make mistakes. Sometimes things go wrong. We should not depend on assumptions and over-confidence to ensure we do what is right. We must follow the safety steps taught us in nursing school every time with every medication and with every patient.
The Five Rights of medication administration are the right patient receiving the right drug with the right dose and right route and receiving it at the right time. And I add to that list of rights that we must always verify with two identifiers to ensure the right patient receives the right drug and dose at the right time and by the right route.
We all make mistakes. I hope you learned from my first medication error. Do not ever shy away from taking responsibility for one's actions. When we admit mistakes we can learn from them and become better nurses because of it.