The biggest mistake made in our facility (as far as med errors) are people hanging piggybacks and not opening the clamps on the secondary tubing. They made it a focus and the incidence has dropped dramatically. I always make sure to see it start running before I walk away, but many nurses still don't do that.

easybreezy, if that's the biggest mistake that's been made in your facility, then COUNT YOUR BLESSINGS. Here's a brief list of the errors that have I have seen in some of the acute care facilities in my area:

Administering Potassium instead of Saline to flush a heparin lock. The patient died.

Taking a pregnant patient on a Magnesium drip to the bathroom, and while doing so, removing the tubing from the pump, failing to make sure that the tubing was clamped, resulting in the patient receiving a 500 cc bolus of Mag. The patient died, although her unborn babies were successfully delivered by C-section and survived.

Removing Epinephrine instead of Ephedrine from the Pyxis machine, resulting in a pregnant patient receiving an IV overdose of Epinephrine. The patient spent several days in the Cardiac ICU.

A resident wrote an order for 500 mg of IV Benadryl, and the nurse administered it without questioning the order. The patient spent several days in the ICU.

Seeing a nurse fail to properly dilute IV penicillen for a newborn, resulting in the baby receiving several thousand times the normal dose for a newborn. The baby suffered no ill effects.

Having a nurse practitioner write an order for IV antibiotics for a newborn that was incorrect. The pharmacist failed to catch the mistake and filled the prescription. The nurse administered the drug. The baby died. Everyone involved was charged with manslaughter, but eventually cleared. The nurse who administered the drug spent several years under probationary status, and ended up in therapy.

Maxine, if you spend very much time in this business, you will find that people make mistakes (no one is perfect), but if you examine each one of these errors closely, and question why these errors occurred, you'll discover that they didn't occur as the result of one bad nurse. Sometimes it's sloppy practice by the hospital; sometimes, it's the result of several people failing in their duties; sometimes, it's the result of poor staffing.

Hopefully, if you are blessed, you will work in a system that encourages you to admit your mistakes, because the results of errors can't be fixed unless those around you know about them.

Wow those are some serious mistakes. Did the family members sue on all those where the patient pasted away? How did the nurse get cleared of manslaughter when their error caused a death?

Those are some scary mistakes. I know that they happen, but I read them and wonder how on earth people do that...we are implementing stricter "high alert" medication double checks.

I shouldn't have maybe said "biggest mistake," I should have said "most common," but I have not heard of anything remotely like what you have listed happening.

Biggest Mistakes
Yes these things can and do happen all over the world.
I have seen some real bobo's where I have worked, not just by nurses either.
The left leg was amputated when the right one was scheduled to be removed.
The wrong TPN was hung because the patients had the same last name both were on TPN, as a nurse I should never been assigned these 2 patients. Yes I made that mistake. No the patient did not die, yes I was disiplined, but also was treated fairly afterwards. We now use stricter rules about patient assignment when names are the same.
Yes I feel bad because the patient did not need the higher dose of Potassium and could have been harmed. However, when I notified the Doctor he said change the label keep running the TPN. Order a new one for the other patient.
so what do you think now?

Research on drug administration errors mostly conclude that errors reported are just the �tip of the iceberg� i.e. that most errors go unreported.
Some health authorities are introducing anonymous e- reporting of drug administration errors and near misses. Other healthcare institutions use a �no blame� culture for error reporting.
I too have seen some serious drug errors including one which caused the death of a patient.

I have been practicing for 15 years and consider myself extra careful when doing drug rounds. Yet, despite this, I have made 2 drug administration errors that required the involvement of medical staff, one was a whole bunch of pills to the wrong man and the other was Trazadone instead of Tramadol to another old man. Fortunately neither of them suffered any ill effects but there was considerable damage to my self confidence and pride.

I would humbly offer this advice when administering drugs. Follow proper drug administration procedures and protocols. Don�t take short cuts. Dont allow yourself to be hurried or distracted

Mistakes
I know what you mean about bobos. I'm a trainee veterinary nurse and things can just as easily go wrong with the administration of drugs to animals.

I remember when I started an early shift at our 24hr clinic, I had to transfer data over from the previous day to the fresh sheet for that day. The dog was on a drip and some of his many medications, were to be administered IV. Later on that day when it was time for her pain relief, I thought it was to be adminnistered IV, however it was supposed to be sub-cutaneous! Luckily the particular drug was also safe to use IV but because of someone's bad writting, I could have killed someone's animal. I've never felt so panicked in my life.

Ginger Snap re: med errors.
Always follow the five rights for medication administration: right drug, right dose, right route, right patient, etc., and use a double-check system such as ask the patient their birthday. Look at their nameband. GINGER SNAP, I enjoy reading your responses; you sound like a well-educated person to me. Sometimes the answers we give are not pretty, but this is a serious job and you sound like you take your responsibilities very seriously. Pls continue in your efforts to educate new nurses and students on this forum. Peaches.