The Rigamaroo works!

Estimates of medication errors suggest that between 770,000 and two million hospitalized patients experience an adverse drug event (ADE--or med error) annually, and 140,000 patients actually may die from ADEs. (1) Adverse drug events are injuries that result from the incorrect use of a medication. Morbidity and mortality from ADEs may cost the health care system more than $136 billion annually. (2) Adverse drug events account for the greatest percentage of procedure-related malpractice claims. (3) These shocking and distressing facts make ADEs a focus for patient safety efforts.



In nursing school you learn all kinds of safe ways to do things--in practice you see the discarding of some of these safe practices and are told that "this is how it is done in the real world."

Well, I am quickly finding that lots of these safeties are saving not only my butt, but the health and well-being of my patients.

Was pulled aside by my instructor yesterday and told to give meds to three patients in three rooms a clinical partner was taking care of--she was doing asssessments and I don't know why the the instructor didn't have her doing meds as well--but I DID look very bored, so...I jumped as commanded.

My instructor took off, and I had about 20 mins until 0900 meds, so I took the opportunity to look up each med in the PDR. Everything looked fine--but there was way more stuff than I have ever given so I was quite nervous. Each patient had 5-6 meds and I was hanging IV Rocephin for the 1st time. My instructor came back, went through the pyxis with me (asked me each drug action, side effects, etc. so I was REALLY glad I had looked them up) then she took off again leaving me to distribute the meds by myself--EEK! I did the five rights 3 times and decided to take each med cup one at a time so I wouldn't get screwed up--remember folks, I am a NEWBIE and super-green! Can you guess what happened next?


I walked right into the WRONG room w/ my 1st med!!!!!!!!!!!

You see, I had the patient's name in my head, but had connected it in my mind with the wrong room number. And here is what saved me--I said, "State your name?" She said it and I was like, "Um, excuse me." Back out to the medcart--checked my 5 rights AGAIN, got my correct room number, walked into the RIGHT room, and gave my meds (after having that patient state her name, checking her bracelet, etc).

Am I stupid??--probably. Did all that I have learned thus far--and actually USING that learning--saved me getting written up and more importantly me harming my patient?? HECK YEAH!

This is also why I pray a lot before going to clinical...

;)

PS-I read somewhere that there are an estimated 44,000 to 98,000 deaths per year related to med errors and the lowest number makes medication errors the 8th leading cause of death in the US.