Temptations that come with a medication error

Alternative Journal of Nursing March 2007, Issue 13 Temptations that come with a Medication Error
Darlene Sredl, Ph.D., R.N.

I made a medication error. A big one! When I discovered my mistake, which was almost immediately, and as I recognized the lapse in procedure that I slid through, something even more egregious took hold of me. I wanted to cover it up…pretend it didn’t happen… just not report it. The urge was very strong. I went back to the large man suffering with terminal cancer. He laid there, eyes wild with pain and anxiety and I knew I had to tell. I had to give him every opportunity to survive my mistake- even if only for another day. As the evening nursing supervisor at a large Midwestern extended care facility, part of my responsibilities includes dispensing medications from the in-house pharmacy. If the central delivery service is late, or a new patient arrives after the last pharmacy delivery of the day, I unlock the in-house pharmacy and take out what is needed. This particular day, Mr. W. was admitted late in the afternoon with many needs. The unit nurse asked for my help as she was way behind in her medication pass. The hospice nurse was finishing his assessment as I walked into the new patient’s room. Later, as the hospice nurse and I strode down the hall he gave me a sketchy report that (I thought I heard) “… and he still needs Haldol, 5 mg IM.” I collected the ampule from the pharmacy and read the label- 1 cc = 5 mg. Just to make sure I looked in the drug book to find that the usual adult IM dose is 2-5 mg. Returning to the floor I knew I had a choice. My responsibilities could easily have been completed by handing the ampule to the unit nurse knowing she would give it whenever she had a chance. From the looks of things that seemed to be at least an hour from now, I thought. I remembered the wild, anxious look in Mr. W’s eyes and knew he might be comforted sooner if the medicine were given immediately. I called out, “Mary would you like me to give the injection?” She was frantically rifling through the tattered pages of the Medication Administration Record (MAR) trying to satisfy the demands of the patients who had now started cueing up for their after dinner medications. Assessing the situation, I knew I would not be much help to her if I insisted on seeing the MAR first. She would have to stand aside and wait while I did the last check, losing even more precious time. So I said, “The hospice nurse said he gets 5 mg, is that right?” She grunted what I took to be assent and I drew up the injection. After administering the shot I returned to the nurse’s station, and there, lying on the desk were Alternative Journal of Nursing March 2007, Issue 13 the patient’s transfer orders. My eyes hit upon, ‘Haldol 1 mg IM q 6 hrs.’ My heart sank. Panic began to rise. Surely that can’t be right I rationalized. Someone at the hospital must have made a mistake I thought indignantly. Remembering the ampule contents of 1 cc=5 mg, I reasoned that they must have meant 1 cc, not 1 mg! But in my heart I knew that wasn’t true; all my rationalizations could not obliterate the fact that I had, indeed, given the wrong dose. That’s when I first felt it; the twinge…the little whispering voice. “Nobody need ever know”, it said. “Just sign it off and don’t tell them. Then no one will know YOU made a mistake. Every one will just assume you gave the 1 mg just like the order says- and wasted the rest. You don’t even need a second nurse’s signature as a witness to the waste. You’re home free! Who would doubt YOU?” I thought suddenly of the devil’s temptation of Jesus when He had spent 40 days and nights in the desert praying. The devil tempted His comfort level by telling Jesus to turn stones into loaves of bread. It must have been very tempting to Jesus having fasted so long- the promise of instant gratification for his hunger. It was tempting to me too. My comfort level would be satisfied if no one knew of my error. No need to do all the messy mopping-up that a med error requires. No need to call the doctor and admit the mistake. No need to tell the Director of Nurses. No need to face the consequences. I sat down at the nurse’s station trying to quell the temptation when the second one came- this one much stronger than the first. It seemed to say, “You just got your Ph.D. in nursing! What will people think? What will people think of YOU? All that education and making such a stupid mistake. Forget it- it will go away. He’s dying anyway.” I thought of the devil’s second temptation of Jesus. High on a mountain, the devil admonished Jesus saying if He were really the Son of God He could throw Himself off the mountain and surely the angels would save Him if He were truly divine. This temptation appealed to personal power just as mine did. But my better Inner Nurse saw the situation differently. Maybe my mistake would look stupid to some, but it also occurred to me that it might also show that I am human- still making mistakes just like everyone else. Maybe it would help other nurses who might have made, or will make, medication errors in the future to own up to them because actually it is the patient who stands to lose the most- not the nurse. Still struggling with my decision, the third temptation packed a wallop so forceful I had to sit down. “You are going to leave this job tomorrow- you could leave with a perfect record- do you really want to spoil your perfect record?” the voice sneered. I thought then of the devil and Jesus standing on the precipice with the devil displaying all the kingdoms of the world. This, he promised Jesus, could all be His if He would prostate Himself and worship the devil. With this last temptation of pride the devil was luring me too into believing my educational attainment made me perfect, lulling me into Alternative Journal of Nursing March 2007, Issue 13 complacency about what I had done, minimizing its importance, and maximizing my pride in leaving this job with my good reputation intact. With a powerful wrench away from the devil’s hold on my attention, I turned toward the med cart, phone in hand.
“Mary, I made a medication error. Where do you keep the doctor’s phone numbers?”

Epilogue:

Before I left that evening I filled out the 'medication error' papers on my mistake. That night at home, I tossed and turned all night. Please God, don't let him die because of my carelessness, I silently begged. Returning to work the next day, my last shift was probably the hardest thing I have done in quite awhile. I knew the staff were planning a "Good-bye" party for me and
I also knew that word of my med error had traveled like wildfire around the building. A
fear that was verified the minute I walked in the front door when the Hospice nurse yelled
out into the hall,
"Hey Darlene, you know that med error you made last night?"
"Sh-h-h, can we discuss this privately?"
"What’s the matter?" He asked, continuing to embarrass me in front of all my colleagues
at the shift report. "I asked the night nurses and they said he slept like a baby- best night's
sleep he has had in a long time. We asked the Dr. to change the order to Haldol 5 mg."

Darlene Sredl, PhD, RN is the author of over 80 articles in professional and lay
journals and two books. Airborne Patient Care Management: A Multidisciplinary
Approach (which has been chosen by the government of Chile as their official air
evacuation manual.) and Nurse Yourself is a humorous and zany book on unusual stress-
relief tips from A to Z for nurses and other healthcare professionals. Familiar with
nursing issues at both staff nurse and nurse executive levels, Dr. Sredl now teaches
nursing to BSN and MSN students at the University of Missouri in St. Louis. Additionally,
she is a licensed pilot and the former CEO of AV-Nurse International, a flight nursing
dispatch company. You may reach her at sredld@umsl.edu

Source: http://www.altjn.com/perspectives/med_error.pdf