Medication error

Specialties Emergency

Published

Hello all,

I work at one of the busiest ER's in the city. Very chaotic and disorganized. I have been a nurse for about 9 yrs and 6 of those I have worked in this kind of setting, so I would consider myself somewhat experienced nurse. Several days ago I had a very unpleasant experience of making a med error. Very dangerous one too and I don't even know how it happened. I was attempting to start an IV insulin on a pt that came with BS above 600. As I was setting up the pump my charge nurse was trying to move the patient ( and the bed ) to the other side of the room because the cardiac monitor on this side was not working. As I always use another nurse to check my insulin with me I asked the second nurse to verify it with me. ON my surprise when I looked up toward the insulin bag hanging more than 2/3 's of the bag was missing. The bag was spiked, tubing was of course primed and it was inserted into the pump. It was connected to the patient but I did not yet program the pump so I had no clue how the medicine could have gotten to the patient. Probably about 40-50 units have infused into the patient. We use Alaris pumps and I remember I had some trouble closing the door on one of the channels. I have administered IV insulin many times with the same pump never had this happen ( Thank God). Patient did fine. We monitored her BS every 15 min, gave her 1/2 amp of glucose and started her on D10 . She was admitted to ICU for monitoring but her stay was uneventful. She was moved to medical floor the next day.

Now my job ( and maybe my license) are in jeopardy. I already spoke to my boss twice but she is being very cautious as to what she says to me about this and she told me not to talk about this. She told me that I'm to expect some kind of corrective action ( not sure what this means) and that this is a very serious matter. I asked her if I'm going to be fired or if there will be any kind of action taken against my license and she didn't comment on this just told me " she wants me to be successful". She says there will be an investigation and she will talk to me next week.

I'm worried sick. I feel better knowing patient is ok but I can't even sleep at night knowing that I might lose my license. Even losing my job would be devastating for me because ER nursing is what I have done and what I see myself doing for the rest of my life. I'm a single mom and my job is the only source of income for me and my daughter. Not sure what I'm going to do if I can't do nursing anymore. My mind is going wild.

I would appreciate any kind of advice or if you have any thoughts about this please share. Anybody had similar experience or have heard of any?

Thanks

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Specializes in Geriatrics, ER, case management.

So sorry this is happening to you OP. It sounds like possibly an issue with the alaris pump. Can you look into doing CEU's about medication errors. There are a lot available on line and it will show initiative when you do speak with your boss again that you have taken steps to give "corrective action" to your self.

Do you have ? If so this would be a good time to call them! With it being a med like insulin I would expect a write up or progressive discipline but hopefully they leave your license alone. We all make mistakes. Hang in there!

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Specializes in Medical-Surgical/Float Pool/Stepdown.

I would be looking to work in a non-punitive work environment that encourages errors to be reported and works diligently to seek out and correct system errors.

This sounds a bit more like a system error although I am not familiar with Alaris pumps (I think we use them in our ICU's but I only take care of Med-Surg and Step-down peeps) as the IV tubing I use shouldn't flow if the cartridge piece is closed/pushed in so it fits into the pump correctly.

Good luck to you and I'm happy that the Pt wasn't harmed. Who knows, this may happen more often than you think and it either hasn't been caught or others are too afraid to report it!

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Specializes in Med-Surg.

We use Alaris pumps, but I have never had this happen when the channel door is closed/locked and the pump hasn't been turned on. Maybe it was a faulty channel or tubing set?

I hope you work in a non punitive facility for medication errors. Hopefully the fact that the error was recognized and reported, and the patient appropriately treated/monitored without major adverse event, will be in your favor and you won't be treated too harshly.

I am glad your patient was okay. Good luck with this, I'm sending positive vibes your way.

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Specializes in Trauma Surgical ICU.

I've seen that happen with alaris pumps. It was with dopamine !! Scared all of us at the bedside to death. Some times the door looks closed but it's not allowing the contents to free flow into the pt. This was about 4 years ago and the pt was fire engine red but ok other wise. We called pharm and the doc. Since then I stay for a few after starting anything to make sure it's working properly

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Specializes in Peds, Neuro Surg, Trauma, Psych.
I would be looking to work in a non-punitive work environment that encourages errors to be reported and works diligently to seek out and correct system errors.

I agree, the university systems I've worked for preform root cause analysis on errors to find out if there are system issues that need to be evaluated. Organizations that look for individual scapegoats are not healthy places to work. It would be different if it were a pattern of behavior for a specific employee but first offense med errors usually lead to a root cause analysis and a "warning" with corrective action plan if no system issues are found.

I wouldn't worry too much about your license, remember it's the board, not your employer who takes action on your license. So even if your employer reports it to the board they will do their own investigation and you typically can have legal representation through that process. That being said I've not known of anyone having their license removed for a single med error.

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So to clarify: the door was closed and the pump was not running but the contents were flowing in the patient or NOT flowing into the patient?

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Oh brother....a nurse for nearly 10 years is involved in an adverse event like this and you'd think you had shown up to work drunk with a loaded gun. This was not an "error". An error would be you thinking you gave 5 units and you gave 50. Something out of the ordinary occurred during the set up. As long as you don't have a dossier of odd events following you, you have nothing to worry about and there's no need to get a lawyer, consult a malpractice carrier etc.

There was no harm, you caught it right away, you notified the appropriate people and the patient received the proper treatment. People need to chill out. This falls squarely into the s*** happens category. Any punitive action here would be ridiculous.

Help find out what did happen. Was it the pump? Was it that after the 4000th time you set up an iv infusion correctly, on the 4001st you became distracted and let it free flow into the patient without putting it on the pump? Who knows? But whatever happens, it should be a learning opportunity specific to this event. Not some punitive BS 40 hours of medication administration CE's or something.

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I actually did some research today and discovered that this is one of the problems with Alaris pumps. IN 2007 Cardinal Health recalled thousands of these pumps d/t similar events. I guess there was a malfunction with occluder springs ( little devices inside the module that regulate the flow of the fluid). There were even 2 deaths reported. I guess when the modules were assembled some of them even came without the springs while other ones came with broken, bent or otherwise damaged parts. What I was not able to find was list of serial numbers of the pumps affected but some of the pumps at this facility definitely are from that era. I went to the company's website as well as FDA and in both cases lists of SN were removed without the explanation. I will try to approach my boss with this next week. I agree with you that this should be a learning opportunity but unfortunately you should have seen mu superiors after this ( they were out for blood). I'm pretty sure I will get disciplined somehow just not sure how severe it will be. :(

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Specializes in Surgical, quality,management.

Your license is not in danger. Look up your state BON and research what people get disciplined for by the BON. Its not a one off insulin infusion error.

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Just curious, was that particular pump taken out of service? And if so, was anything found to be wrong with it? If not, if there is any way to identify it, it needs to be removed and checked out!!

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Specializes in Family Nurse Practitioner.

If this is how your management responds to an equipment related med error it sounds like they are thinkng of a reason to get rid of you. OP, now is the time to start putting out new apps and once you get a new job, resign from that unsupportive environment or go zero hours.

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