1st med error?
hi all, i am a nurse of 2 months nearing the end of my orientation. last night, i had vitamin b1 mixed in 100mLs of NS to administer to an ETOH pt (my admission at 10:30pm). i was on days for a few weeks and i did many of these infusions before, however they are usually mixed and sent up by pharmacy. on nights, however, there is no in-house pharmacist, only a remote. anyways, i saw the order at like 11:30 ish, didn’t get around to administering it until almost the full hour later. the pyxis had me pull a 100mL NS bag and 2, 2mL vials. i only required 2.5 mLs from the vials. so i pulled everything, i used a blunt fill needle to withdraw the prescribed amount, wasted the rest, injected it into the NS bag, spiked and hung the infusion. i was slightly questioning it because i usually don’t mix meds in that way, BUT i am new to nights so i figured this is how they must usually do it if theres no remote pharmacy. if it was anything other than a vitamin i would have honestly asked, especially since the reconstitution i have done so far is just with powder meds like antibiotics. i guess i should’ve asked, however, since i gave this med decently often on days, i didn’t think anything of it.
my preceptor knew i was going to hang this, bc i told her before i was doing it, she saw me at the pyxis taking out the bag and 2 vials, but it was only after i administered it that she came up to question me and said it might be an issue with the fact i mixed this, since pharmacy is usually supposed to do it. i couldn’t help but be freaked out about it, i get super anxious feeling like i did something wrong, and i like to believe i am diligent and careful when i pass my medications. she only thought to bring this up bc another nurse with an ETOH pt across the unit got the same order, just with more vials + NS and… he injected the ordered dose into the bag and hung it too. she told me they usually don’t mix vitamin b1. couldn’t find a policy for mixing vit b1 in our facility’s database. we went to ask a nurse from ICU and per their educator we can mix vitamin b1 but we basically shouldn’t have to, bc it’s a pharmacy thing. but we don’t have pharmacy at night. so i think my preceptor’s point was that i should have asked before mixing it, but i had no idea it wasn’t something usually done by nurses on nights, and surely i can’t (and obviously wasn’t) the first one to encounter this order during the nighttime.
i wasn’t SUPER upset bc honestly the night was sm worse in other ways but that did kinda make me feel like crap lol. especially bc she said it was technically a med error which sounded so scary out loud. if that’s a med error then what about all the ppl who use normal saline flushes to reconstitute things like protonix? my facility’s policy is that we have to use sterile water vials but NOBODY (except for me haha) actually does this. technically, this is a med error too? but it’s not nearly as scrutinized. anyway, preceptor was not by my side for the administration but knew that they ordered a vitamin infusion and saw me go to the pyxis for it, so had she questioned it at that point i would’ve stopped in my tracks. i just genuinely had no idea