A Nurse's Insight: How I Prevented a Potentially Fatal Mistake

Working as a Medical Assistant (MA), I encountered a situation where my quick thinking may have saved a patient's life. I will share with you the story of a time I stopped a potentially fatal medication error from happening.

Preventing a Mistake: The IV Medication Incident

It was a routine evening on the ward when I received a medical order to administer an Intravenous (IV) medication to a new patient. The drug was something I hadn't been previously familiar with, and the dosage was indicated in International Units (IUs). However, the doctor had ordered it in milligrams (mg), which caused me to question the discrepancy. After attempting to convert the units on my own, I decided to seek clarification from the hospital pharmacy.

Conjuring Confusion: The Pharmacy Interaction

The pharmacist, whom I shall henceforth refer to as "Robert," was a gruff individual known for his less-than-favorable attitude toward nurses. When I attempted to explain the situation, he was initially unresponsive and dismissive. His response was predictable, a monotonous and uninvested, “There’s no conversion rate for IUs to anything.”

Knowing the potential severity of the situation, I persisted. I explained that the doctor had ordered milligrams, but the pharmacy had sent IUs. After a brief conversation where Robert grumbled about the challenges of working with nurses, he became more attentive. I inquired about the patient's weight and handed him the IV bag.

The Consequence of My Actions

Without hesitation, the pharmacist advised me not to give the IV. This was a critical moment, and my instincts kicked in. I immediately returned the IV to the return bin and proceeded to administer other medications. Moments later, the doctor appeared on the ward, seemingly aware of the situation. When he asked about the IV, I confirmed that I had returned it as instructed.

The Broader Impact of My Actions

While it may have seemed like a simple interaction at the time, the consequences of my actions were much more significant. By refusing to administer the medication, I potentially prevented the following:

Drug Overdose: Administering the IV without the correct conversion could have led to a dangerous overdose. Incident Investigation: Medical errors often lead to thorough investigations, which can be detrimental to the reputation of the healthcare facility. Negative Consequences: Had the error gone through, the pharmacist and doctor might have faced severe repercussions, including financial penalties or disciplinary actions.

As a result of my actions, I ensured that the patient, the pharmacy, and the hospital remained unharmed. I not only saved the patient from a potential overdose but also kept the license of the pharmacist and doctor intact. Medication errors are a consistent risk in the healthcare industry, and it’s crucial to maintain vigilance and adhere to best practices to prevent such incidents.

Conclusion

While I may not have been a nurse in this particular situation, my experience highlighted the importance of questioning and verifying medical orders in a healthcare setting. Nurses, medical assistants, and pharmacists all play critical roles in ensuring patient safety, and preventative measures are essential in minimizing the risk of medical errors.

Keywords:

nurse mistake prevention hospital medication errors pharmacy conversions