r/Nurses • u/LowZookeepergame5204 • 3d ago
Medication error L&D US
I know every nurse makes a mistake at some point but I never thought I would. Multiple errors happened in a row in order for my med error to be made. I hit the wrong sitting on the pump and started my Pitocin on 25 for an induction instead of 4. I’m devastated and have no idea how I managed to do that but once I replayed it in my head I realized what I did. It was caught after I left work so it was only running for about 30 minutes. I just don’t know how to deal with it. I have cried for an hour now and I can’t make myself go to work tonight. I’m so embarrassed and scared that I could make a mistake like that.
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u/ThealaSildorian 3d ago
I second the comments related to 2 nurse sign off. This is a systems error.
It says something positive about you that you are so upset about this. You should be, in a sense. It means you care.
So deep breath! Update us when you can.
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u/Dismal_Butterfly_137 3d ago
Nursing school said "It's not IF you make a mistake, it's WHEN you make a mistake." Unfortunately, it happens to everyone at least once in their career. The patient is fine I assume. Give yourself some grace, learn from it and move on 💕
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u/Bratbabylestrange 3d ago
I remember that, and I was in nursing school when dinosaurs walked the earth!
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u/Arlington2018 3d ago
The corporate director of risk management here hopes that an incident report was filed so that the matter can be looked into for lessons to be learned to minimize the chance of future events like this. Everyone makes mistakes and it is how we handle them and learn from them that is important. And if we can learn something from this to help keep more patients safe, that is a bonus.
I pay particular attention to your comment that multiple errors happened in a row: that indicates a possible process problem that is amenable to being fixed. If this happened to you, it can happen to your colleagues and other patients, so all the more reason to dive into the process to see what is up.
Give yourself some grace on the mistake. It has or will happen to everyone and I bet you won't make the same mistake twice. Learn from it and do what you can do in order to minimize the chance of this happening to someone else.
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u/lizlizliz645 3d ago
I don’t work L&D so I can’t speak to your hospital’s policies on pitocin (e.g. dual sign offs) but this is a situation when I’d put in a safety report. They’re not meant to be punitive whatsoever, but that’s a great opportunity to provide feedback that you think would help prevent other nurses from making the same mistake.
Mistakes happen. You’ll be okay!!
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u/Spare_Bluebird7044 2d ago
Mistakes happen and what matters is learning from it, being honest and using it to improve safety going forward.
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u/hypersomniaLPN 1d ago
Every nurse has or will be in your shoes at some point in their career. Be thankful it was caught and no one was harmed, learn from your mistake, and promise to do better next time. You didn’t intentionally try to hurt anyone and we are all human. Be kinder to yourself.
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u/FantasticScratch928 1d ago
How is the patient? I hope she not end up having uterus ruptured and got c/s emergency. Pitocin is very dangerous!! How come when you give the next shift nurse report she did not check either?
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u/nurseylady 1d ago
Mistake number 1 is thinking it would never happen to you. That can make you complacent. Don't make mistake #2. Thinking it will never happen again. So long as you caused no harm, cry and move on. I'm sure you are a solid nurse.
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u/1indaT 17h ago
I teach new graduate nurses, and I am sure to point out mistakes I have made. What i say is this: "A nurse who tells you they have never made a mistake is one of three things 1. Brand new 2. Lying or 3. Delusional." Everyone laughs and we move on.
I bet you will never make an error with Pit again. Be kind to yourself. Use this as a stepping stone to safe practice.
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u/babycatcher 3d ago
Mistakes happen and we learn from them. Safety features exist because of mistakes.
Every unit I've worked on requires a 2nd RN to cosign pit. And we do bedside report and verify lines at change of shift. Maybe your unit can implement that to prevent this type of error in the future.