Worst med error - stories? - page 3

by Rhon1991

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Brennas dad told a 'worst med error' story under 'interview questions asked....' and I thought I would start a new thread with hopes of some comedy relief and STORYTIME! We love stories, dont we? Well, here is mine. It was... Read More


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    Thank you all for those stories!!
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    Talk about resuscitating a thread from the dead!
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    WOW on the IV Nimodipine... That sucks.
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    Wow. I know the original post is 10 yrs old, but I was astonished that the poster didn't think it was a HUGE mistake to send a patient off unit with unused meds hanging and obviously connected to the patient! When we send people off unit, we minimize the drips to only the must haves and label lines in big letters to minimize confusion.
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    Ahhh I was asked this question in an interview once! The only one I can think of (that I know of) was pretty bad... I had a patient who pretty much went into respiratory arrest (ended up being a hugeeee mucus plug), we had to RSI him, standard dosing of etomidate&sux were given... although I did have a new grad with me and I was letting her draw up and give the meds... she asked what one she should give first... well before I could say anything Mr. hot shot doctor tells her "oh you know the answer to that... think about it!" shes stumbling and he goes well what do you think you would want first, a sedative or a paralytic!! she got that question right and then I whispered "etomidate sedates!"... anyways we do all this... once he is intubated he starts fighting the vent so we start a propofol gtt, still going crazy, we add some fentanyl... Well here is where I go wrong. We got these new pumps and there are a few differences between them and the old ones.. Well I'm explaining to the new grad that I am going to start the fentanyl gtt at 50 mcgs/hr on the pump... and I hang it, we put in the numbers and start it.. it starts running... So then we are talking about all the meds and I'm telling her the usual ranges for all the gtts, she goes "but with the fentanyl you mean 50mcgs per KG per hr though right?"... I'm like what! No! That would be like 4000mcgs/hr! She points at the pump and here I see my mistake and OMG I hope he felt good. I guess they changed the way we dose it on the new pumps and I didn't even realize it! Luckily it was only on for like 5 minutes but thats still like 300mcgs! No wonder the vent kept alarming... maybe a little chest wall rigidity?.... agh!
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    Quote from Rhon1991
    Brennas dad told a 'worst med error' story under 'interview questions asked....' and I thought I would start a new thread with hopes of some comedy relief and STORYTIME! We love stories, dont we? Well, here is mine.

    It was within my first year of ICU (2nd yr as RN) and I was learning how to pull arterial sheaths post cath with the charge nurse. He sent me to sign out some Versed. I got it out of cabinet and decided against my gut to sign it out right then, I will just do it later, got to hurry! The order said to give 2-4mg. This guy BTW was mainly healthy, alert, 40's - 50yo. (Thank God) We go thru the procedure and all went well. Well, about an hour later he is still very sleepy but responding to my questions. So I figure I may as well get his bath over with. Do that. He is STILL sleepy and snoozing. I go to sign out the versed. To MY horror, I took the 5mg ones - Ive only seen the 2mg vials..... I gave that man almost 10mg of Versed!!!!! I go back in to assess him, yes he is breathing ok, no wonder he slept thru that bath! So I call the doc and it was 'just watch him'... so LATER, the 3-11 charge nurse then comes in (versed given around 9-10a) to say hello to him and he smiles brightly and says Good Mornin! He didnt even remember his bath.....
    I guess that retroamnesic effect is no myth!


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