Medication Errors and My Mental Health

My Worst Day

In my final preceptorship as a nursing student, I made a medication error by not giving a patient insulin after checking their blood sugar. According to “Reducing Medication Errors in Nursing Practice,” medication errors are one of the most common causes of unintended harm to patients, and one-third of those errors occur during administration.

I swore that would be my first and last medication error.

Fast forward several decades, I worked per diem in a regional emergency department (ED) and a small, rural ED near where I live in Canada. The rural ED was staffed by one registered nurse (RN) and one licensed practical nurse (LPN) on days and evenings, then just one RN on nights. I was working a day shift and, due to a sick call, there was another RN with 38 years of experience with me.

When our shift started, only one patient was in the ED. A pediatric patient, who had been involved in a single motor vehicle crash (MVC), was brought in by the family to our rural ED and then sent to a regional center for computed tomography (CT) imaging. However, because their vitals were stable and due to ED overcrowding at the regional center, the patient was sent back to our small rural ED for observation and pain management. The next day, after reading the CT, the radiologist advised us to send the patient to a pediatric trauma center, four hours from our location, for further care. The call to transfer the MVC patient came in just as we were caring for another pediatric patient, a 3-year-old experiencing status epilepticus.

It happened again.

The 3-year-old patient came into our ED with their mom, who reported the child had multiple seizures at home without a previously diagnosed seizure history. Upon arrival, we put the child on the scale to weigh them, not recognizing that the scale weighed in pounds, not kilograms. Our scale had to be manually changed between pounds and kilograms, but it was usually in kilograms since it was a pediatric scale.

Our rural facility has minimal staffing: Our registration clerk did not come in until 7:45 a.m., and our physicians were not always on-site and had to be called in to see patients. My RN partner went to register the patient and to notify the physician of the patient’s arrival. As I put the child in our resuscitation room, they started to seize; I attempted to ensure their airway was not compromised while yelling for help. My RN partner came back to assist me. When the physician arrived on-site, we gave the patient intranasal benzodiazepine, initiated intravenous (IV) access, and gave the child an IV dose of benzodiazepine. The child kept seizing, so our physician consulted pediatrics at the regional center for further direction. We were instructed to give a loading dose of antiseizure medication and then to hang an infusion of the same drug – as the child continued to seize.

My RN partner was managing the patient’s airway while our physician was trying to coordinate the transfer to a higher level of care. We called for staffing support from the acute care floor because our other patient was ringing for help, asking for pain medication.

The inpatient nurse who came to help was not ED trained or familiar with the emergency care environment. I went to prepare another dose of the antiseizure medication for the patient. If you do not regularly work with pediatric patients, you need to know that their medication dosing is weight-based, calculated in kilograms. I prepared the medication, not recognizing that I calculated the dose based on the weight in pounds instead of kilograms.

I took the medication into the room and double-checked my calculations and dose preparation with my RN partner. The pressure of trying to treat the patient, do the paperwork for the transfers, await two EMS crews, and act as the site educator weighed heavily on my mind. The patient left our department around 8:30 a.m. with the IV antiseizure medication infusing. I then called report to the regional ED. Finally, it was time to clean the resuscitation room and maybe finish my coffee.

Trial and Error

Thirty minutes later, I received a call from the regional ED informing me that I had made a medication error with the transferred seizure patient. My heart sank. No one wants to make a medication error, especially with a child. The good news was the seizures had now stopped, but my immediate shame and guilt did not.

I filled out an entry in the reported learning system (RLS), sometimes called event or incident reporting systems, an electronic reporting system for medication errors - including near misses - that are nonpunitive for actual patient or staff safety events with the goal of improving processes to avoid similar instances in the future. Per protocol, I notified my ED physician of my mistake, then sat down and cried.

One of the staff from the regional center where I also worked called me and asked, “Could you not see the child was smaller than what you documented?” I had no words. I had another nurse colleague who was also a very close friend text me to tell me some comments from staff, such as, “She is the educator; how can she not know better?”

The Mental Impact of My Medication Error

I was ashamed. I avoided picking up shifts in the regional ED for a few months after the incident. I was embarrassed by my medication error and the impact on the child and their family. I was also struggling with the “educator perception of perfection.” Some people believe that as an educator, you are the end-all of information. At the core, I am human and make mistakes. I felt that as an educator I was in a fishbowl and should not make errors, medication or otherwise.

I struggled to sleep; I started binge eating to work through my emotions. I resolved that I was inadequate as a nurse. I was short-tempered at home and not confident in any medication administration, especially with pediatric patients. I feared being analyzed whenever I was back working in the rural ED. I became impatient, insecure and ambivalent toward my job.

My husband recognized the situation and encouraged me to seek talk therapy to resolve what I was feeling. He gave me space initially, but when it started to impact my home life and my health, he reassured me that I am a great nurse and that I had to move on from the negativity I was swimming in.

Unique Challenges of Rural EDs

I started to do some research and recognized that I was not alone. Working in a rural ED is stressful due to the lack of resources, everyone knowing everyone, and not always having a physician readily available, leading to increased decision-making for nurses. Patricia Dekeseredy and team found that the challenges nurses face in rural EDs add to potential compassion fatigue, burnout and other occupational mental health concerns. I consider this blog an opportunity to advocate for rural nursing and the stacked challenges that rural nurses face.

Strategies to Mitigate Medication Errors

It took me three years to return to work in my rural ED. I wrote an open letter to my colleagues as part of my healing. It is important to learn from mistakes and work to improve processes to help avoid errors in the future. Here are a few of the lessons that I carried forward after my medication error:

• Double-check patient weights and ensure that weights are in kilograms, not pounds, before doing medication calculations
• Use closed-loop communication by repeating the weight as an extra check
• Do an independent double-check of high-risk and pediatric medication dosing to confirm accuracy
• Fill out event reports per organizational protocol, including near misses
• Cross-train staff from other units if nurses are expected to assist in the ED or other specialty units
• Be compassionate and supportive of yourself and others if medication errors occur
• Learn from mistakes. Foster a just culture that encourages open dialogue about medications errors or near-miss medication errors.

Mitigating Future Errors

Medication errors happen on every floor of every hospital, regardless of the rural or urban setting. We need not shame each other when mistakes happen and should encourage reporting these events when they occur to mitigate future occurrences.

Have you made a medication error or had a near miss? Did you report it?