I didn't know if I had written something about it, but then I clearly remember the incident and made a report about it. I had my night duty and a nurse went to the pharmacy to get her medications. She asked me who I was and I told her my name then she's having some dilemma if she should ask me something that's bothering her thoughts, and made a decision to ask me anyway. It was the medication error I could clearly and vividly remember. (If you have read my post about ERTAPENEM and IMIPENEM instance) then you could relate.
Here's our conversation:
RN: miss, ano gani name mo?
RPh: Tin2, ngaw?
RN: ah ikaw to nagserve SALA no? ang kay patient (private) bala na Ertapenem haw?
RPh: huo, ngaa aw? ano to haw? (I thought it was totally over because it had been a month or so)
RN: ah, kay nakareceive ako bi memo. nag IR ka to?
RPh: huo, nag ubra ko to IR, ano ang memo?
RN: ahh, wala na may ginpa ubra sa imo? pila to gani imo ginserve?
RPh: 6 vials kay 1g, ay, indi gali. 3 lang then may standing pagid sya na 3 kay q8h.
RN: IR lang gid ya ginpa himo sa imo?
RPh: huo, ano haw?
RN: ah, kay wala man kamo ya ga hatag bulong mo (in a sarcastic tone, more like talking to herself rather than me)
Then she was gone, and I didn't understand our conversation and her point. I didn't get the memo and whatever. I know she's the one who gave the first dose and definitely, she made the medication error. I can feel her anxiety and denial, because she's a newbie, and she may be suspended or worst evicted.
She came back hours later and ask same questions again, I went out to talk to her.
RN: kadumdum ka pa to?
RPh: huo eh
RN: wala naman lang to tani, kay hipsan lang naman to tani galing kay nabaton ang IR mo
RPh: sang pagkabalo ko na nagsala ko ya, nag IR ko dayon kay sala ko mo, wala ko gahipos lang
RN: basta nagbasa gid ko ya, tanan na order sa chart gin basa ko, dayon sang pagpakita na lang sa akon sang vial, didto ko na confuse kung ano ang ginhatag ko.
RPh: ano ang memo haw?
RN:.....
I was taken aback, I keep on recalling the facts and what she told me that they would just keep silent about it, until I made the incident report. I was like, I made an error and I reported it immediately because I know that it was my sole responsibility and I'm risking the life of the patient, I only wanted for them to get well and not to kill them by my error. I reported the error so that the physicians will know about it, and if there's any complications, they could resort to some curing and they would know what was the cause. If I keep silent about it, how many more patients were given the same wrong treatment? How many more errors will be silenced? We should learn to accept our mistakes, because we are not perfect and who would like to commit an error? No one wanted to make a mistake, no one wanted to be blamed but then there are times that we can't avoid these serious circumstances, we just need to accept the facts that we are human and we're not perfect, we need to be reminded that we have rooms for improvement and experience.
Tani, kabalo man ang nurse mag accept na may sala siya, indi niya pag i-deny sa iya self na tawo lang siya gakasala man, kag indi lang tani pag hipusan ang mga bagay na seryoso kay sila ga handle sang patient kag indi lang basta-basta ang kabuhi sang isa ka pasyente. Kung nurse siya na tuod kag ga lantaw siya sang sitwayson, kabalo gid siya kung ano ang dapat niya himuon, indi ako ang basulon ya ngaa nag IR ko, kay gin amin ko na gani nga may sala ko. tani siya man, accept niya na lang na sa amo to na mga tini-on nagkasala man siya.
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