Of Med Errors and Brain Farts
I read the physician's order carefully, looked up the medication in the nurses’ drug book, and consulted with our pharmacist before I gave it. While signing the medication administration record (MAR), I read the order again, and I did not see the same dose I had read the first time.
Image Credit: Dawn Huczek
Immediately the blood in my feet rushed up to my ears and I was lost in pounding waves of white noise. Fuck, fuck, fuck, I made a med error, and it's a serious one. Of course, I didn't say these words out loud. Instead, I carried the patient's chart and the empty, pre-filled syringe to the nurses’ station. Putting them in front of the charge nurse I said, "I think I just made a med error, a bad one. Look at the order and the syringe label. Tell me what I've done." She stopped what she was doing. She read the order and examined the syringe. "You gave the right dose. You didn't make a med error. Now breathe." The pounding breakers of white noise in my ears subsided into the gentle lapping of my breathing. Another nurse came to my side saying, "I know exactly what you're feeling.”
I felt relief. My patient was safe. It was a medication I am not very familiar with. That's why I read the order carefully, looked it up, and consulted with our pharmacist. All I can determine about my confusion after giving the dose is that I had a brain fart. Somehow my eyes and my brain disconnected after I gave the medication, and the order unexplainably failed to make sense. That's the best I can come up with: a brain fart.
Later, my coworkers told me their stories of making med errors. We all make them. I didn't know that when I was a new grad.
It is unbelievable to me as I type this, but it is true: in nursing school I had an instructor who told our class that she had never in her thirty year career, ever made a medication error. Never. And I was young, and shiny, and idealistic enough to believe her. Seriously, I did. So when I made a medication error during the first couple months of my new-grad job, I was sure that I was not cut out for nursing. At that time, my coworkers didn't gather around offering support like they did recently. No, I was written up, and had to call the pediatrician and tell him that I had forgotten to hang a dose of ampicillin. He was more sympathetic than the day shift charge nurse back then. I made other medication errors too, nothing serious, but enough to consider quitting nursing during my first six months of practice.
Then I met one of the best nurses I have had the pleasure to work with. For some reason, she decided to mentor me. I confided to her that I considered quitting nursing, because I made med errors, and that my instructor never had. She laughed.” If that instructor of yours never made a med error, then I'm thinking she's too dumb to catch them. You are so crazy. Let me tell you about med errors..." She was a great nurse, not a perfect one.
She showed me how to string nursing tasks together like a pearl necklace, and eventually I gained the confidence needed to stay in nursing these past twenty-four years. I still make mistakes from time to time. I take responsibility for them. I learn from them. I am compassionate towards my coworkers when it happens to them. Nursing is not a risk-free profession.
And sometimes I have brain farts.