Med Error

  1. Well, it's 9 months into my nursing career and I was starting to feel good about my nursing abilities. And then it happened last night....my first med error

    My patient was on a fentanyl drip at 3 mL/hr which is 150 mcg/hr. At about 0430 I'm changing all my IV bags and finishing up because I was going to leave early since I felt ill. I was going to write out report and another nurse was going to watch my patients until day shift got there.

    Anyways, I'm wasting the fentanyl with another nurse in Pyxis and I come out to the station and my patients O2 sats are in the 80s. I go in there to investigate and tell her to cough and deep breath and she's not responding. She looks bug eyed and is staring at the ceiling. I check pupils, they are sluggish and reaction. Next, I think to check her blood sugar since she's on an insulin drip. Then it hit me, check your IV pumps. My fentanyl was running at 113 ml/hr! Instead of adding volume to the pump I had adjusted the rate. We estimated that she got 600 mcg of fentanyl. I wanted to throw up.

    The other nurses grab Narcan and are bagging her while I call the on call anesthesiologist. Luckily she was very nice about it. I told her what happened and the first thing she says is, "She's going to be ok." We gave her an amp of Narcan and afterwards she looked bright eyed and bushy tailed. Of course after the incident I'm checking on her every 10 minutes, asking her if she feels ok. She asks me eventually, "Am I dying?" OMG! This poor lady thinks she's dying because of what I did.

    It was hard for me to recover after that but I sucked it up and finished my shift. Everyone was supportive and shared stories about their mistakes.

    The only thing that I felt good about is that I figured out what the problem was fast.

    I'm sharing my story so that everyone can learn from it. Check your IV pumps!
    Last edit by incublissRN on Mar 7, '07 : Reason: added info
    •  
  2. 13 Comments

  3. by   CHATSDALE
    you learned something and you helped advise others so that other errors can be prevented
    the lady was probably concerned because of all the confusion and the rechecks..i am so glad that she is going to be ok
  4. by   muffie
    nobody's brain is any good at 0430

    glad you caught it

    glad pt was ok

    live and learn

    check, double check, triple check
  5. by   steelcityrn
    what a horrible experience, thanks for sharing...yup, I agree on the re-checking
  6. by   CRNI-ICU20
    You did ok....you owned it....took steps to correct it....learned from it...and then shared it....
    This is the sign of a good nurse...
    We have all made some real boner mistakes, dear....don't let it shake your timbers....you'll do well...because you learned...and next time, you will be more astute and double and triple checking....
    Sometimes....even after 22 years, I will ask another RN to check all my drips with me....to be sure, when I am changing anything....in fact it is policy to have insulin gtts. and calcs. checked with another RN....and anything that is resp. suppressive....or vaso-active....I will have another check with me....
    This isn't about me being insecure....or not knowing....it is about me understanding that I am human, and I could potentially harm someone....so I double check and sometimes with another...
    it's all good...
  7. by   GeminiTwinRN
    Ouch! It's great that you caught your mistake, and the outcome was good.

    It's policy at my hospital that 2 RN's must check all settings on PCA's. I'm hypervigilant about checking those pumps!! I'm sure you will be too, now.

    Mistakes happen. You've had yours. Now you'll know, so don't beat yourself up.

  8. by   Cmariehart
    I don't mean to hijack but since we're talking about med error's... NEVER hold a coumadin unless told to do so by a MD....
  9. by   RN BSN 2009
    You did great on re-assessing her... fentanyl is a dangerous drug to mis-administer. Glad everything turned out ok!
  10. by   cardiac.cure03
    That's good everything turned out okay.
    I wanted to mention also, the pumps we use on our floor have something called "collegue guardian" on it. You can scroll through a list of drips on the IV pump. If you pick fentanyl, for example, it'll ask the concentration of the med bag, the pt's weight, etc. And if you input a rate that's higher than recommended, it'll beep at you and ask if you're sure. It's an EXCELLENT feature and I think all IV pumps should have something like that. It's saved my butt already.
  11. by   canoehead
    incubliss, I know about 10 regular ER patients that would make you their fairy godmother for an error like that, lol. No worries.
  12. by   morte
    your error also speaks to the fact the we shouldnt work when we are ill.....the brain just doesnt function as well
  13. by   incublissRN
    Quote from morte
    your error also speaks to the fact the we shouldnt work when we are ill.....the brain just doesnt function as well
    How very, very true. I have been ill for the past 4 days and just returned to work last night. I should have requested to leave a lot earlier the night I made that error. It's too bad I felt like I had to "suck it up" for the rest of the shift.
  14. by   incublissRN
    Quote from adidasgirl0699
    That's good everything turned out okay.
    I wanted to mention also, the pumps we use on our floor have something called "collegue guardian" on it. You can scroll through a list of drips on the IV pump. If you pick fentanyl, for example, it'll ask the concentration of the med bag, the pt's weight, etc. And if you input a rate that's higher than recommended, it'll beep at you and ask if you're sure. It's an EXCELLENT feature and I think all IV pumps should have something like that. It's saved my butt already.
    That sounds like an awesome feature! It would have been nice if it would have saved my butt too

close