Medical Errors--Is There Anyone Who Hasn't Slipped Up?

I wonder if there’s a nurse out there who hasn’t made some sort of preventable medical error. Does that nurse exist? If so, I am not that nurse.

When I first started a three-year hospital-based diploma nursing program, students, no matter what our level of education, were not permitted to have jobs, period. Just prior to my second year, there was a significant change in the cost of the program (upward, of course) and administration decided to loosen the reins a bit and allow us to work, ostensibly to help our families foot the bill for the increase.

Still, there were restrictions. We could only be employed by the hospital, junior students could work as nurses' aides and seniors could work as medication nurses. I began as an aide in the emergency room and loved it so much that I wasn’t interested in moving up the career ladder to a job passing meds. Believe me, the pay increase was not that attractive. But, one evening I caved in to the pleading of a supervisor and reluctantly agreed to give meds on a neurosurgery floor with a full census—about 40 beds.

With all those post-op neuro cases (cervical fusions, laminectomies, Crutchfield tongs), you can imagine the numbers of requests for pain medication. It was overwhelming—to the point that I was soon behind with all the scheduled meds and frantically running sprints up and down the unit’s long hall, while trying to juggle it all. I was 19 years old, new to the unit, unfamiliar with all the patients, and dodging angry family members demanding I deliver the pain med that was requested 10 minutes ago. Not that any of this is an excuse for what came next.

I had my 9 p.m. meds doled out into their little soufflé cups, positioned on the appropriate medication card, all on a single tray (remember, this was the Dark Ages). I’d become exponentially behind schedule as the evening wore on, so I was still playing catch-up (unsuccessfully) and rushing from room to room. I whipped into a private room to see a young man of about 21, sitting up in bed watching TV, obviously lucid. "Mr. Smith?" I asked. "Yes," he answered. If I couldn’t trust an alert 21-year-old to know his own name, whom could I trust? So, not taking the time to check his wristband, I dropped the med into his open palm, handed him a cup of water and he dutifully swallowed the capsule. All good—until I walked into the next room to discover the occupant was Mrs. Smith. I’d given her sleep med to the young man next door and his name wasn’t Smith.

I was lucky that it was a harmless way to learn a tough lesson. The only result of my negligence was that Mr. Smith likely got the best sleep of his life and I got an incident report tacked onto my personnel record. I learned a lot that night. Most important was that I never again gave a med without checking off all the safeguards. I learned to say no to the powerful and not allow myself to be bullied (no matter how sweetly) into something I knew was beyond my capabilities. I also learned that the regimented schedule of bedside nursing was not for me. I happily stuck to jobs in ambulatory care for my entire 10-year hospital career. Both patient and nurse were better off for that decision.