I remember when I made a med error, well, technically it really wasn't a real med error because it was given at the wrong time. Coumadin at the facility I worked at gave it at 9pm verses 9am and I was a brand new grad and felt so much pressure to pass as fast as I could considering I had a little over 40 pts and very little experience. I accidentally saw 9 o'clock and considered it as part of my morning med pass. Right after I gave it I realized what I actually initialled and when I told my supervisor about it she acted like it wasn't a big deal and to just let the 2nd shift nurse know about it, well, needless to say at the very end of the day the supervisor approached me and made me sign a med error report who went to the DON whom I was called in to see and even though everyone acted liked it wasn't a big deal it sure looked differently on paper and in my permanent file. I just think looking back on it that the main problem wasn't just making a med error but the stress of trying to pass too many meds to too many pts in too short of time allowed. I think it's ridiculous how many meds needlessly pass nurses hands a day, I know, I know, there's a shortage, but my God man, a new grad and all that pressure, the packet (whatever you devise) should take this as the primary concern when the mistakes occur, isn't the same when MD's Dx? Take care of the root of the problem instead of treating the symptoms all the time?