This is in response to the question asked in the March 2003 "Vital Signs:" "Does your facility still view med errors as a "nurse's problem?"

Just who else do you think should bear the blame when a nurse makes a med error?

When an individual makes a med error, he or she needs to accept the responsibility for that action, accept the consequences, learn from the mistake, (and allow others to learn from it,) and move on. An incident report needs to be generated, as well as a sentinel event report, if indicated.

Why should there be any need to shift the blame onto someone else?

Giving meds these days is almost foolproof, given unit dose medication, access to the pharmacist who has all the information regarding any prescribed drug, including drug interactions, a vast array of drug handbooks for nurses, and the Internet--not to mention the PDR!

I, frankly, am always amazed when I see nurses failing to double check their Heparin and Insulin dosages with another RN before administering them. I was taught that this was Standard of Care.

I am also amazed when people claim that they made a mistake because "the vials looked similar" (please!) or "somewhat put the wrong medication in the drawer," and the next person grabbed it, "assuming" it was what was SUPPOSED to be in the drawer. To me, that is inexcusable.

I, personally, know of an instance in which an RN gave PITRESSIN instead of PITOCIN, IV, to a labor patient! The results were disastrous! And this was an OB nurse! What could have possibly caused her to make this error? Her excuse was: "The meds were stored in alphabetical order, and I grabbed the wrong one." Don't people READ LABELS, anymore, especially when drawing meds from a multi-dose vial?

Don't nursing schools teach "The 5 Rights of Medication Administration," or pharmaceutical math, anymore? I think they do. Why, then, are there so many med errors?

Consider this: When I was a Navy Hospital Corpsman in the '70s, I worked on all the units. We had large multi-dose vials of stock medications on the floors. On p.m.s and nights, there was no in-house pharmacist.

When you wanted to give medication, you first calculated the dosage using your pharmaceutical math. If you were at all unsure, you conferred with another corpsman or two, or nurse or two, to check your math (and this was before calculators!)

You also checked the PDR to familiarize yourself with that medication, reading up on normal dosage ranges, drug interactions, contraindications, etc.

I can remember having to dissolve Morphine tablets in injectable MS to give injectable Morphine, which required using pharmaceutical math.

I can remember having to use other types of Insulin syringes to give Regular Insulin, which required using pharmaceutical math.

I can also remember having to calculate complicated pediatric drug dosages using Clark's rule and Young's Rule, as our only stock of every drug was meant for adult patients.

We also very commonly had to split p.o. meds with a knife blade (no pill splitters existed back then) and mix our own IV piggyback meds (antibiotics, etc.)

No one made med errors. To do so would have earned one a Captain's mast, not to mention potentially being "busted" to a lower rate (paygrade) and perhaps even dishonorable discharge. Besides, we were well trained in complicated pharmaceutical math in corps school.

When I went to nursing school in 1981, I was amazed at how the availability of a 24 hour in-house pharmacist and, particularly, the widespread use of unit dose medication made giving meds so easy.

Still, even though I have been an RN for 22 years, I am not embarrassed to check my drug calculations with a colleague if I am uncertain as to their accuracy. I still double check Heparin and Insulin with another nurse before giving it, as I was taught so long ago. If I am unfamiliar with a medication, I still look it up in the PDR.

Please, fellow nurses, let's not get like the ever-increasing members of our society who are continually looking to "blame" someone else for their own actions.

Also, let's not use the lame excuse that "I was just too busy" to check, double check, and even triple check the effects of meds we are giving. A patient's life depends on it.

Regards,

Stephanie Tate, RN, CNOR, CLNC

Paradigm Legal Nurse Consulting

3008 NE Alberta

Portland, OR 97211

legalnurseadvice@justice.com

503-970-6574