Medical problems significantly impact society’s health and have caused great concerns due to the increased mortality that it causes. There are two most common major medical errors, namely error of omission, which occurs due to failure of an action to be carried out, and error commission resulting from an inappropriate action (Johnson & Sollecito, 2018). Most of the medical errors that occur are, however, preventable, and appropriate measures should be taken.
I experienced my first medical error during my last clinical rotations as a senior nursing student. The registered nurse who guided me during my preceptorship gave me a challenge. She assigned me a patient and instructed me to act like a qualified nurse, and I accepted the challenge. That would have been my opportunity to see how I worked independently. The patient assigned had hypokalemia, with a potassium level of 2.9 mEq/L. The physician prescribed intravenous therapy of 40mEq potassium to be administered.
The RN who served as my preceptor was informed of the prescription, and she assured me that I would manage it because it only involved the incorporation of drugs. After confirming the next steps I needed to take, such as asking for an Intravenous infusion pump to run it and working out my drug calculations with her, everything was in order. I finished it off by incorporating the KCL into the Intravenous line. It was a simple task, but now the mistake appears. When she arrived at the patient’s house to check on me regarding the KCL order, she noticed that the patient’s current IV was D5LR.
In other words, I combined a KCL with a D5LR when it wasn’t supposed to be done because they were incompatible. KCL must be combined with a 0.9% NaCl solution, also known as normal saline. So, I made that mistake because I was a student and didn’t realize it wasn’t compatible. Only a few minutes had passed when we realized our mistake, so the client only received about 5 to 10 milliliters. Fortunately, the client was uninjured.
I informed my clinical instructor and the team manager about the incident. The registered nurse was held accountable because she was supposed to mentor me and follows me around at all times. She filed an incident report and informed the patient and the treating physician of the mistake. I was also required to write an occurrence report and hand it to my mentor. After that, I was told to give a discussion to the class about the drug compatibility of KCL with other Intravenous fluids so that my fellow medical students wouldn’t have to make the same error. These were the repercussions that the Registered nurse and I both had to bear.
As a nursing student, I should have done more research about the KCL integration or, at the very least, read the drug research guidebook in advance to avoid the mistake (Rodziewicz et al., 2022). Because I had performed it a few times without knowing whether it was compatible with the D5LR IV fluid, I became a little overconfident. Additionally, the Registered nurse who was in charge of watching over me ought to have been present when I hooked up the IV fluid (Vanessa, 2019). That, in my opinion, would have avoided the mistake. If you are unsure about a medication, talking to the pharmacist was my main takeaway from this. Now that I’m an RN, I still adhere to that mistake. It served as a lesson.
Johnson, J. K., & Sollecito, W. A. (2018). McLaughlin & Kaluzny’s continuous quality improvement in health care. Jones & Bartlett Learning.
Rodziewicz, T. L., Hipskind, J. E., & Houseman, B. (2022, May 1). Medical error prevention. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499956/
Vanessa. (2019). Measurement of Patient Safety. Psnet.ahrq.gov. https://psnet.ahrq.gov/primer/measurement-patient-safety
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