Vital Signs September Issue - School of Nursing - SDSU

Medication Error
I am tired. It is my third, twelve-hour shift
in a row and I am feeling the ache in my feet, my
back, my eyes and my soul. It is Father’s Day. I
attempt to call my dad; no answer, so I send my
brother a text message to pass on my well-wishes.
My preceptor has left me to my own devices
and has not moved from his chair. The patient load
is light, but the odd timing of their cumulative medications
is throwing off my time management; not
just 9, 1, and 5, but 11, 11:30, 12, and PRN pain
management. The cumulative medication administration
timing is keeping me from reading their
charts, looking at the big picture.
A 0900 medication is missing; the inhaler is
not in the Omnicell (medication pyxis), not in the
refrigerator, not in the lock-box in the room. I enter a missing med. When it becomes due again at 1700, I
am exhausted, dragging, and feeling the weight of being a student and a full-time employee simultaneously.
The medication is available in the Omnicell. A single, lonely inhaler in a cell by itself, I take it
out and add it to the pile.
Entering the patient room, I marvel at his ability to maintain sleep. The six tablets of methadone
have finally worked; his bed is at a 45° angle due to his breathing problems (pneumonia and COPD), he
is slumped to one side, drooling, twitching occasionally, the pain of his skin cancer temporarily forgotten.
I check his respirations; they are slow and even and within normal limits at fourteen. I scan his
wristband into the Bar Code Medication Administration Program (BCMA), thankful that I did not wake
him. I scan his IVPB and prepare it for infusion; I scan his oral meds and check that I have enough applesauce
to administer them with his difficulty swallowing.
The inhaler will not scan. The cursed missing med, finally available, will not scan. I walk over to
the satellite pharmacist to explain the problem. She comes back to the patient room to attempt troubleshooting.
My ever-absent preceptor comes over and also attempts to troubleshoot. Nothing works.
The pharmacist goes back to her office and prints a
new barcode. Finally, the medication is scanned in. I wake
my patient and start his IVPB, I give him his oral meds, I
hand him his inhaler to use. He recognizes it as a new
medication and asks me what it is – I tell him the generic
name I see on the screen and the hard-copy due list. He
looks skeptical and asks what he is allergic to… I check his
allergies, and the brand name of this medication is listed
among them.
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