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I Made A Medication Error

Updated: Oct 18, 2021

"I made a medication error. I gave the wrong dose to a cardiac surgeon's patient."

My nurse, 1st year out of nursing school on the Pediatric burn unit, is weeping with terror in her eyes with me in the treatment room. I inquire what measures she has taken to this point and we walk to see the child. She has told a pediatric resident who examined the child and seems stable at this point. I know the protocol as the Nurse Manager for medication errors, but do I remember how I felt and how my Head Nurse handled my first med error in the Peds ICU? As I look at her face, I clearly can feel the same flood of shame, guilt, and pain when it was my error. And here is where the First Caritas Process to practice loving kindness with self and others becomes relevant. Like my previous Head Nurse, I told her she would need to call the surgeon and tell him the details and how she has followed up thus far. "When he arrives on the floor, I will go with you." I could see relief in her eyes and she thanked me for the support. I reminded her we all make mistakes, even the cardiac surgeon. And the impact of his mistakes are likely more significant to the child.

In hindsight, I wish I would have been mature enough to offer her a few tools to take home to give herself some loving self-care, but that was not role-modeled so that piece did not happen. That added piece of self-care is included in the Caritas Process so well and I feel helps a nurse dealing in crisis to complete the loop to continue to be compassionate in her care of herself and the patient.


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