ProNurse

I have only been qualified for 6 months and haven't made an error yet (touches wood). But I see a lot made. Only last week on a late shift notice that the staff on the previous night had administered co-codamol AND paracetamol together...oops!

What was the outcome of your error? Did you report it or did someone else? Did you sign the drug out with somebody?

Yes to reporting it myself. I just didnt get a witness as you are supposed to, i know this for morphine and temazapam and methadone. Ive never even heard about subutex, and due to the ward being hectic i put it in the trolley which was a bad thing as its meant to be locked up in the mini safe in the drugs cupboard. as  if i had done thus i would have known to sign it out correctly. what a dum moment of mine. although its a bit of passing the blame or maybe a cry for support, but should i really be left to my own devices like it. I mean im competant to an extent. god i dread to think what the outcome will be.

without a doubt, checking is my new middle name, and thank you stuart, reasurring in many ways. Just it falls on a weekend then followed by two days off. When really i could do with speaking to our manager. hey ho, what will be. GULP!!

I made and reported my drug error, the patient was not harmed but I was and am devasted by the realisation that I could have caused harm  to the patient.  My confidence has been totally shattered.  I tried to carry on working and " get over it" but i was hypervigilant ++ and became ill.  I am currently on sick leave and really dont envisage returning to work as a nurse.. A job I previously enjoyed. I am unable to accept the risk  of making another error, high in these days of high stress and low staff. 

Craigyanus- Over thirty years of nursing in a diverse range of specialities and I've never heard of Subutex. On looking it up I see it's Buprenorphine, which I obviously do know. In my Trust, when we order CDs, the order book goes to pharmacy and then is sent back with the drug, and the porter delivering it has to get a registered nurse to sign for accepting it. So, for us, it would be difficult not to realise that you're dealing with a CD. What I'm saying is that maybe it's your Trust's policies which are at fault. Don't be so hard on yourself. It was a mistake. You were busy. And perhaps your Trust policy isn't adequate. We've all made mistakes and I've seen much worse than that. I shouldn't think they'll be too hard on you, honestly.

Oh Freddie that is awful I am so so sorry that has happened to you! A consultant once told me of a fatal error he made , which was really in fact a just a consequence of a known but rare risk of a procedure.He was devastated but every year the patient's wife sends him a card to tell him to always remember regardless of the outcome he had the best of intentions and was trying to help him.Remarkable woman but she is right ! He is a fantastic Dr and mistakes can happen despite our best efforts at times.I hope you sort this out for yourself xxxxxxxxxxxxxx

Ah, pet. I really feel for you. I understand that you'd be worried but please do bear in mind that many, if not most of us, have been in similar situations. It was a genuine mistake. We all make 'em. Give yourself a break. I think the deputy manager who handed them to you needs to take some responsibility too. Actually, it's probably not that serious, you know. If you worked on the community, you'd be setting up infusions with CDs with no second nurse checking them. And there are areas in hospitals where they have dispensation to give Oromorph from the trolley and Trusts where it isn't a CD. So, you see, perhaps this would be classed more as an administrative error than a drug error. You didn't give a wrong drug or wrong dose. What do your employers say?

Shouldn't there be double checking (ward base or home based)... lengthy process but piece of mind etc  (experience seen in care homes i work at) 

At the start of my nurse training we were all gathered together in the main lecture hall for a series of introductory talks.  The lecturers (most of whom were nurses) were stood around the perimeter of the room.

The first speaker got up and asked for anyone who had ever made a drug error to put their hand up.  He swiftly raised his own hand.

Everyone, including all the lecturers, just looked at each other, puzzled.

He asked again.  And, to our surprise, one or two of the lucturers hands began to be nervously raised.  Many more remained, resolutely, by their sides.

Finally, after asking again and getting one or two more responses and lots of stoney looks, he said that every nurse in the room ought to have their hand raised because every nurse will have made drug errors.

The point he made was that we are all human and so will make mistakes, that when mistakes happen honesty is important, and that you don't have to beat yourself up trying to be 'Super-Nurse' to be a good nurse. Making the odd mistake is inevitable and you'll burn yourself out and be no use to anyone if you try to be 'Super-Nurse'...

burn out is when you on longer care about the job and it becomes just a job. There are many burnt out nurses in practice sadly but the fact that you still care about doing a good job means that you are not burnt out. However, burn out is treatable and preventable with a good supervisor / mentor

in reply to stewart, yes you are right ,i dont think there are many that have not made a mistake in our time , i was nursing for that past 40 years but now retired last november, i have made a mistake in my time ,but as long as its reported as soon as possible its sorted out , and although you feel very bad at the time ,you remember and dont make the same mistake twice. take care all .

Croatoan says ...

People worry too much about making drug errors. They happen and rarely, very rarely, do they cause harm.  (Although of course any harm is not a good thing.)  We should learn from mistakes, we do all make them, after all, but we shouldn't worry ourselves to death over them. I echo what others have said, report any errors and don't try and cover them up.  Having said that I'd like to bet we all make more drug errors than are reported for the simple fact that we don't notice them at the time, and as nothing happens to the patient, it's never picked up.

I'd also like to bet that poor handwashing, poor basic hygiene and lack of basic care, prevalent on busy wards, causes far more serious problems, and deaths, than does the odd drug error.   But few of us make ourselves ill by worrying about it.

Hear hear!

Cheers,

Stuart

Trying not to be too harsh here as you're obviously suffering, but bottom line is you made an error that all of us make and you seem to have completely over-inflated its importance.  I can't tell you to get over it, though I'd like to, because you obviously can't, but really it's the equivalent of pulling out at a junction and making a car brake too hard to avoid hitting you.  In such a situation no-one would hand in their licence and swear never to drive again because of it.  Especially as I assume no-one was hurt.  

As it is the taxpayer has wasted a fortune training you, and presumably paying you while off sick, the profession will lose a perfectly good nurse, and you will have given up a job you enjoy all because of something which, if not exactly trivial, is really not that serious at all, and just about every nurse has done at some time in their career.  

Not sure what ill health retirement means.  i wouldn't think you'd get paid anything as the NHS is not at fault so i don't know if it's any different from just giving up work.  By giving up you'd avoid having to declare your ill health when going for other jobs.  As an aside, can you not look at deployment to an area where handing out drugs isn't required - if it is only drugs that cause you problems?

On the other hand the whole almost catastrophic thinking may have brought to light an underlying anxiety problem.  Perhaps, if you've not already, you should look into treatment/therapy for this.

Again, apologies if I do come across as harsh.  It seems such a waste of a career.

All the very best whatever you decide. 

I'm sorry to hear what has happened to you.  I found talking about my drug error helped, try your previous tutor, staff wellbeing service if you have one.  Don't just sit and fester like I did.  Take care