The 6 Rights to Patient Safety

In nursing school, the 6 rights of medication administration were drilled into our heads. It felt like we were quizzed on them in every class and clinical. The message I got about medication errors was simple: avoid them!

I agree that we need to do all that we can to avoid making medication errors, but I’ve also learned that nurses are human, and humans inevitably make mistakes.

We break wine glasses, we have fender-benders, we misplace our checkbooks -- unfortunately, mistakes occur in the professional sphere of our lives, too. Even when we try to be as careful as possible, due to the sheer number of medications a nurse passes day-to-day, the chances are that a mistake will happen.

No nurse starts their work day with plans of passing a wrong medication, but there comes a day when an accident happens, and he or she does. So when the new nurse makes an error, how does she process it if she’s never been prompted to think about it?

One day, a co-worker mentioned a med error she had made. She volunteered a personal story of when she gave an antibiotic to the wrong patient. I was really surprised to hear this because I knew this nurse was thoughtful, experienced, and careful. She didn’t even know she had made the error until the next day -- the night nurse discovered the empty antibiotic bag with the wrong patient identifier on it.

This made a big impact on me. It highlighted how unintentional med errors are; oftentimes you don’t even know you’ve made them until someone else discovers them.

This nurse felt guilty about her error. It was scary to think you could hurt someone unintentionally when your life’s work is dedicated to helping others. She prompted me to think about the aftermath of med errors, something my formal education never prepared me to think about.

Hearing my co-worker’s story helped me think about what I would do if I were to make a medication error, whether small or serious. What is the responsibility of the nurse to the patient that has been given the wrong medication? Do you tell the patient you’ve made the error? You don’t want to add to a patient’s anxiety in an already difficult time, but you don’t ever want to lie to your patient, either.

Does it depend on the type of error involved? For example, do you tell the patient if you gave them an unordered multivitamin? Do you tell the patient if you gave them their neighbor’s Lisinopril, even if their blood pressure remains stable? What about more serious errors, such as administering the wrong dose of chemotherapy?

How does the nurse deal with the guilt of making an error that affects her patient?

I think one answer is doing what my co-worker did: Being brave enough to share the errors you’ve made with other colleagues. It reminds us we’re not alone in our own shortcomings.