Need help with transcutaneous pacemaker incident

  1. I'm currently under fire from my ICU manager because I administered "Ativan 4mg IV Now" as ordered by the physician, to a patient who was delerious, restrained at wrists to bed, and had a transcutaneous pacemaker delivering 80 shocks/minute (the transvenous pacemaker was not working due to not being advanced far enough.) An earlier 1mg dose did nothing for the fellow. The only effect of the 4mg dose was therapeutic----the patient slept for 3.5 hours before again waking up, pulling at restraints and required more sedation.

    The manager's position is I should have questioned the size of the dose. It does not matter to her that I gave the 4mg slowly over 6 minutes (three times slower than the Nursing 2003 drug handbook allows).

    My position is this was an appropriate and safe order. I'm looking for either supportive literature or even better, an expert witness. I have grieved this through my union. We believe administration is targeting me due to my position on the bargaining team (we are currently negotiating a new contract.) The case is now going to arbitration and we are about to file an Unfair Labor Practice against the hospital.
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  2. 15 Comments

  3. by   nowplayingEDRN
    I would suggest going to Medscape.com and doing a drug search on Ativan. Gather as much info as you can to support your position. Including the recommended administration rate and the rate at which you administered the Ativan. May I ask....did you document in your note that you administered the Ativan over "X" number of minutes??
  4. by   lindalee
    Here is my take: Bottom line, pt was able to sleep. Was he compromised in any way? Did his sats remain adequate? Tie the manager up with a transcutaneous pacer for a few hours, perhaps she will be a little more understanding. Sometimes our patients exceed recommended doses--histories of alcohol, drug abuse or whatever require higher doses. This is what makes nursing so much fun--Your patient was fine yet the powers that be must second guess your judgement--Another example of what is happening in nursing to decrease job satisfaction.
  5. by   JohnnyGage
    It sounds like under the circumstances it was an appropriate order. Everyone responds to drugs differently -- I have given pretty hefty doses of Ativan to some patients without adverse effects. In our unit, when someone is TC paced we usually use Versed, actually (more of an amnesic effect).

    I would be questioning what kind of analgesic was administered as well. After all, Ativan won't do anything for the pain involved with TC pacing.
  6. by   Dierdron
    Though I did not physically chart the six minute administration, I have witness statements from other nurses that I have always been observed administering lorazepam very slowly and always dilute with NS.

    Interestingly enough, the physician who ordered the 4mg of Ativan went on record as saying he had MEANT to order Haldol 4mg IV. At first, he said he DID order Haldol and wrote this on the physician order sheet in the medical record. Fortunately, he was in the ED at the time he ordered Ativan by phone. Two RNs overheard him and wrote statements on the incident report I filled out. Had nobody overheard the order besides myself, I'm confident I would already be unemployed. My understanding of haloperidol is that this would not even relieve the anxiety, much less the pain. It would just physically sedate the patient, rendering him unable to communicate his discomfort.

    I can only hope the patient was not experiencing too much pain. His heart muscle was intact. The problem was completely electrical; therefore, the transcutaneous pacemaker captured at 20 mA. But looking back on this, the only thing I could have done better would have been to actively seek morphine or other analgesic AS WELL as the anxiolytic.

    I don't think the patient remembers any of this (fortunately.) Whether it's due the the amnesia qualities lorazepam does possess or his delerium, I can't be sure. Probably a combination. He now has a permanent inplanted pacemaker and is doing great.

    We (the union and I) will announce our intention to seek an arbitrator this week. I'm seeking a complete expungement of the written warning from my record. Before this, my personell file was spotless. Administration decided to skip the first and second warning and went straight to the final warning and 90 days probation.
    We think my involvement in the bargaining team is what lies behind this targeting (new contract negotiations are currently in progress).

    I have some positive leads on expert witnesses already (MD and PharmD). I'm considering calling our local poison control center and see if a Toxicologist could offer a statement on the lack of danger 4mg of Ativan poses for a patient monitored in the ICU (respiratory lead and continuous Pulse Oximetry.)

    If anybody has any other suggestions though, I'm all ears.
  7. by   RNforLongTime
    SOunds like a tough situation all the way around! Keep fighting and good luck to you.

    There's been plenty of times where I've given pt's 4mg of ativan and sometimes more!

    Good luck!
  8. by   Gardengal
    Dierdron,
    You do not mention if the patient had a protected airway withan endo tracheal tube. If the patient had an et tube and was that wild, 4 mg probably would not be out of line. With an unprotected airway I would question going from 1 to 4 mg without question. Tou also didn't say th etime frame between the previous dose of 1 mg and your 4mg dose, giving a total 5mg in what time frame?
    Typically if you need another vial for a higher dose (and ativan frequently is 2mg/vial) this should at least casue you to think caution at the escalation . If the airway was protected, and the patient appeared uncomfortable I would agree with giving additional med and 4mg would seem OK if planning to continue with the TCP.
    Even if the airway was unprotected, and I personally disagree with the rapid escalation of dose, I can see how it could easily happen. Sometimes in our zeal to make a patient comfortable we overestimate dose (esp in elderly although age wasn't stated as an issue here). I believe that if the wasn't a protected airway it should have generated discussion with you as to safe practice and give an area for education, but if you had no other issues of care I do not believe it should have warranted a discipline. Typically a first infraction does not incur a written disciplie, unless it is similar to a previous issue of a verbal warning or there was obvious harm to patient or negligent thought or act.
  9. by   JWRN
    I say it was appropriate. And you pushed it slowly. However, you stated in your post that
    "My understanding of haloperidol is that this would not even relieve the anxiety, much less the pain. It would just physically sedate the patient, rendering him unable to communicate his discomfort."
    The issue I have is that I hope you were not giving the ativan as an analgesic, remeber ativan has no analgesic properties, it is only a sedative. The patient may have been asleep, but he may have still been feeling the TCP firing.

    Good luck with this. Hope all comes out well.
  10. by   rstewart
    In my view there may be some room to debate the clinical appropriateness of the Ativan dose level this patient received. The age of the patient, size etc certainly would be considerations. Whether or not you had another patient if the patient was not intubated might be another (ie. could you give this patient your undivided attention?).

    On the other hand, the drug was administered in the enviroment of the ICU: monitored (vitals, O2 Sat, etc.) Airway adjuncts readily available if not already in place, benzo antagonists (romazicon) readily available, trained staff (ACLS, procedural sedation etc.) present etc.

    There is a reason Ativan comes in 4mg as well as 2 mg vials...in at least some cases that dose is appropriate. Sure, if I were to second guess, I would suspect that a lesser follow up dose (1-2mg) with an appropriate analgesic would have been preferred. But in no way could this be considered some gross med error.

    But we aren't really talking about optimizing patient care here anyway. Rather, we are talking about another game of Blame the Nurse. The doctor orders the marginally high dose, the pharmacy/pharmacist approves the marginally high ordered dose----but only the nurse is considered for discipline.

    The only person who should be disciplined here is the lying dog of a doc. If he lied with no adverse outcome/patient injury, can there be any doubt that he will try to lie his way out of an event which does? Liars like this should not be entrusted to provide care. Unfortunately, as we all know nothing will happen with this doc.....for docs it was a misunderstanding, or an error in communication. For nurses, this will be one more doc we have to tell our peers, "document everything, CYA etc. cause if something goes wrong he will try to blame/hang you for his mistakes". Anyone who has ever worked in critical care knows what I mean.

    I am curious...since there was no adverse outcome: how did this situation come to light?...How did this manager get wind of the scenerio and decide it should be reviewed etc?
  11. by   Dierdron
    The manager found out about this because I wrote the incident report and gave it to her. I had to because the Dr wrote in the Medical Record I gave the wrong med. It should have been a dead issue with the incident report since I had two other RNs signing it stating they heard the Dr. say "Ativan 4mg IV Now".

    I found the full prescribing info from the drug maker. It supports my case very well. The drug manufacturer lists 4mg as within the dosing range; states there is no dosage adjustment needed for age, hepatic impairment, or renal impairment; and says that the majority of patients who receive 2-4mg for preoperative sedation are still able to follow commands. The following link will take you to the pdf format file.
    http://www.fda.gov/cder/foi/label/2001/18140s027lbl.pdf

    I could not really have a stronger case to take to arbitration. I appreciate everyone's supportive comments.
  12. by   gwenith
    HAng in there and lots of luck!!!!

    (((((((((((((((((HUGS TO YOU)))))))))))))))
  13. by   rstewart
    It is a shame that the OP has to defend themselves in such a manner. Whatever happened to the concept of encouraging the reporting of medication errors so that they may be analyzed for the purpose of designing systems/practices to prevent future errors? I would fire off a letter to the appropriate hospital committee describing the punitive reporting environment at the facility in general and in that department in particular. (His/her manager will love her for that---lolol.)

    I do have one caution to the OP regarding proper dose administration. While I appreciated the link to the FDA (always ready to learn new things) I think the OP is taking certain information out of context. Specifically, the information that age is not a consideration when considering appropriate dosing for Ativan. I maintain my original position that it is. It is well known that elderly patients especially those who are very ill or debilitated or who have limited pulmonary reserve are at particular risk for problems with Ativan. There are also clinical studies demonstrating significantly increased sedative effect on those individuals over 50. My point is, I would use caution with respect to healthy adult information for the elderly or otherwise to prove that the dose given was entirely appropriate for this particular patient. I would emphasize the care that was given to proper monitoring, slow administration etc in defending my actions.

    Obviously this physician and manager have some sort of ax to grind with the OP; He/she is fortunate that they have a meaningful forum to defend his/her actions. For those of us who are not organized, an unfair disciplinary action would no doubt be likely.
  14. by   Dierdron
    My plan for the presentation of the caution I used will be:

    1. Checked order with senior ICU RN (who agreed to appropriatness)

    2. Patient's weight 89 Kg (very muscular/robust 90 year old) (Nursing 2003 Drug Handbook lists upper dosing levels at 0.05mg/kg up to 4mg may be needed. 89x0.05=4.45mg

    3. Administered 3 times slower than literature allows

    4. Patient continued to pull at restraints until very end of drug administration (titrated)

    5. Patient on 5 wire ecg monitor and continuous SAO2 (described to lay arbitrator as: monitors keeping track of every breath patient takes and second by second blood oxygen level; would alarm if levels of either dropped too much). RN always within visual sight of patient. Patient remained hypertensive and tachypneic throughout night

    6. Will discuss risk vs. benefits of administration. (risk of patient working through/around restraints and pulling off pacer wires if not enough sedation administered.) Patients undergoing this level of noxious stimuli for hours are more likely to need the highest doses of anxiolytics.

    7. Flumazinil/Romazicon 30 feet from patient in OmniCell drug dispensing machine.

    8. Ambu-bag 2 feet behind patient's head at all times.


    Thanks for the suggestions. Any other suggestions are welcome.
    Last edit by Dierdron on Aug 4, '03

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