Tsering Lama Tamang
George Brown College
March 22nd, 2018
When I was working in Nepal as an RN at the general ward, I had an incident. I administered a maximum dose of the opiate drug to one of my patient. It happened while checking and distributing a controlled drug. I was giving the medication to my patient, and instead of Diazepam 5mg, I gave Diazepam 10mg orally. I realized the mistake during documentation and charting.
My first impressions were of disbelief and horror as it was my first error. I was confused, felt upset and embarrassed. I had checked the drug and didn’t notice my mistake. I remembered talking with the other staff nurse during medication administration. I felt ashamed and angry thinking how I distracted myself during an important task. Due to of my ignorance, I was unable to provide standard practice care and was also playing with the life of my patient. I had failed my profession, patient and myself as a nurse. I knew that I was accountable for my action and should be responsible for it. I was worried about the mistake I made and had to prevent my patient from any potential harm. Even though my shift was over, but I wanted to stay there and check if the patient had any side effects from the overdose of medication. I informed my supervisor about the situation and asked permission of staying there and take action for the mistakes I made. I reviewed the pharmacology drug book to know more about the medication, its doses, and side effects. I researched about the medicines from the internet as well. My patient was just lying down on the bed, and I was feeling helpless. I felt anxious, crying and felt like a murderer. I felt like I was responsible for saving lives but not for killing them. At one point, I felt that maybe I wasn’t suitable for taking care of the patients and should leave the nursing profession. We informed about his condition to the physician. Thankfully, there were no side effects that were seen in the patient. He was just feeling drowsy because of the drug error and was recovering well.
I felt that I need to concentrate more, not being complacent during medication administration. I learned to be more careful and responsible. I will never let such incidents to happen again in my practice.My supervisor also suggested me to be more cautious as I was putting my patient’s life, my career and the hospital’s in danger. I learned the meaning of being accountable, responsible for the patient. I learned how small mistakes could take someone’s life. In the case of emergency, nurses need to be calm and have the patience to think and make decisions.
Drug administration is crucial as it includes public safety and follows the principles that are laid down by the law. A nurse needs to support the eight rights during drug administration and is accountable for their actions and omissions.
Although I followed the local policy and procedures, unintentionally I administered the incorrect drug doses. I had up to date training, but this incident reflected that it’s easy to get distracted when checking and administrating drugs. It there is any error then appropriate actions need to be taken, but many nurses fear the disciplinary action and loss of their clinical confidence. At first, we need to acknowledge our mistakes and make a reflection through our experience to avoid them from happening again.
The administration of medicines is an essential role of the nurse. Drug error is expensive and can cause harm to the patient, the hospital and to the nurse who administered it. Through this incident, I realized that I should be more aware of the client’s well-being.
This mistake became a lesson for me from which I learned a valuable lesson. I will never allow myself to be distracted by anyone in future that includes other staffs, patients or relatives during medication administration. I realized my mistake and educated myself of not repeating it.