There is no greater moment of feeling defeated as a nurse then realizing you made a mistake that resulted in a medication error. Regardless of whether or not it was caught in time, or if it caused harm to the patient, it rips any nurse to the core. One of our main staples is “Do no harm.” No one wants to knowingly hurt someone, yet we are humans and will ultimately make mistakes. It is tragic, and even those small errors can leave a lasting effect on a nurse.
From every error there is an opportunity to learn and grow, that way the error is not repeated again. There are steps in place to help prevent medication errors, we all know the six rights: right patient, right medication, right dose, right time, right route, right documentation. As long as we are following these guidelines, we should not have errors any more right? Well, in a well-controlled situation where every patient is stable and nurses have the time to thoroughly check everything, then of course not.
Unfortunately, in the real world a patient may be erratically climbing out of bed, and we are in a rush to grab the medications needed to calm them down, yet somehow during rush we fail to realize that we grabbed the wrong one and administered it. Does this scenario make the error ok… of course not, but it sheds light on how mistakes may happen.
Errors still occur, even in facilities where scanning medications a requirement. Unfortunately there are times when we give medications without scanning, like in emergent situations. This seems to be an ongoing battle for nurses, finding the time to really LOOK at what we are giving and following protocol to scan every medication, every time. There are many high risk medications, which can be mistakenly given in place of a prescribed medication.
How can that situation be rectified? We could make sure that high risk medications are in a drawer of the Pyxis by themselves and include a specific count. In addition, we will all make mistakes, but we need to remain vigilant in taking the time to pause and make sure we are following the six rights.
The numbers are staggering in the amount of errors… “Since 2000, the Food and Drug Administration (FDA) has received more than 95,000 reports of medication errors” (U.S., 2015). That equals out to be around 6,333 a year, 121 a week, and 17 per day. Overall, the numbers sounds relatively low relative to the volume of medications dispensed annually, but we all know that even 1 medication error a day is too many.
The next time you go to just quickly give medication to a patient please, for their sake and your own follow you six rights, really look to see what you are giving, you have the time and the patient deserves your time. I know from experience the terrible guilt, disappointment and anguish that can follow you once you realize that you have made a medication error. It can happen to any nurse, none of us are exempt, we are all human.
U.S. Food and Drug Administration. (2015, July 27). FDA 101: Medication errors. Retrieved August 3, 2015 from http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm048644.htm