My involvement in the drug error is as follows. I was working on the night shift as the only qualified nurse with 2 nursing assistants. The late shift decided to administer the 10pm medications as a way of helping me. This however was key in me making the error that I did. If I had been left to do the 10pm medications by myself, this error would not have occurred.
Patient PF was given her medication by the late staff, however she had spat them out. On going to give her these again, I also repeated her liquid medication which she had actually taken with the late shift before she spat out her tablets. PF took half the liquid before giving it back to me saying that she had already taken it and it was just her tablets that she didn’t take. She accepted the tablets no problem from me. I checked the BNF to see limits of medication and knew the extra that she had was well within the maximum dose. I also knew that she was not naive to medication and had been taking this medication for some time without any adverse effects. I checked her observations and BP, pulse and temp were all within normal limits. I continued with getting the other ladies ready for bed and carried on with my regular night time duties and once the ward was settled I filled in the datix form to report the error. It was at this time that I realised I should have notified someone earlier of the error. I contacted the AMART team as it was my understanding that they triage the calls to the duty doctor overnight. I discussed the situation with them and we mutually agreed that as PF had suffered no adverse effects from the medication that the duty doctor did not need to be called at the late hour (0200hrs). Agreed that the consultant would be notified in the morning and the SCN would be automatically made aware due to the datix form being completed.
On discussion with the SCN following the error, I now realise that I made some procedural mistakes when managing the...
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