[cheshirecat]

I know of a nurse who misread a prescription and gave 50mg of morphine instead of 5mg IM. She checked the drug with another RN (all controlled drugs must be checked by 2 people over here) and gave it. She had to open 5 vials to give this dosage. Her excuse - she had gotten mixed up with pethidene. Patient survived but it does worry you.

[Sweetooth EMT-P, RN]

This is a very sad situation for both the family of the patient and the nurse and her family.

We all make mistakes, unfortunatly this one cost someone their life. I am not minimizing her error as I feel, like many others do that red flags should have been going up many times over.

I think this nurse is going to need a lot of prayers and support because she is going to be guilt ridden probably for the rest of her life.

swtooth

[squeakykitty]

Originally Posted by CraigBSN02

-The nurse had to get THIRTY-TWO vials of Dilantin from 3 seperate Pyxis units.

-The nurse had to start a second IV to administer that much Dilantin.

All of this would have also taken some time, time enough to think about what she's doing. And the nurse didn't question 32 vials and having to go to 3 pyxis units? I learned that if you have to use more than three, to double check.

[Angie O'Plasty, RN]

Originally Posted by squeakynurse

All of this would have also taken some time, time enough to think about what she's doing. And the nurse didn't question 32 vials and having to go to 3 pyxis units? I learned that if you have to use more than three, to double check.

I'm so paranoid that if I have any questions, or if I don't use a medication enough to feel comfortable with it, I'm on the phone to Pharmacy verifying stuff.

[kitty=^..^=cat]

Considering the magnitude of this error, $200,000 seems like a really low settlement amount.

[dijaqrn]

There has to be more to this..........
No one noticed this nurse drawing up 32 vials??????????????

[ingelein]

Seems so odd that she wouldnt have confered with fellow nurses about such a wierd dosage?Or better yet paged the MD to clarify.Or pharmacy as Angie posted.

[RNsRWe]

Ok, I know this wasn't suggested anywhere as yet, but the only thing I can POSSIBLY imagine that could cause an experienced nurse to be this far off base is if she was so severely distracted, perhaps under the influence of something, that she simply could not think straight.

There's just no other reasoning, in my mind for this scenario going through the nurse's head: "MD has just told me to give 8000 mg of Dilantin. Ok, I'll go get the med from the Pyxis. Hmmm, according to my math I'm gonna need alot more than what's here; I need 32 vials. Ok, I'll gather it all. Gee, wonder why there's only ten in this one? And only ten in that Pyxis? Man, I'm cleaning out ALL the Dilantin from the unit! Ok, have it all. Drawing up vial one.....four.....seven.....nine....gee, seems like alot of work. Drawing up vial 11.....17.....20.....24. Whew, this is taking ALOT of time! Never had to do THIS much Dilantin before. Never saw anyone else do this either. Oh, well....drawing up vial 27.....30....32! Gonna need two bags for this....and start another IV. Gosh, I hope I don't have to do this again in a few hours!"

Which is why I can't imagine a sober, non-impaired nurse doing this.

[MrsWampthang]

Originally Posted by RNsRWe

Ok, I know this wasn't suggested anywhere as yet, but the only thing I can POSSIBLY imagine that could cause an experienced nurse to be this far off base is if she was so severely distracted, perhaps under the influence of something, that she simply could not think straight.

There's just no other reasoning, in my mind for this scenario going through the nurse's head: "MD has just told me to give 8000 mg of Dilantin. Ok, I'll go get the med from the Pyxis. Hmmm, according to my math I'm gonna need alot more than what's here; I need 32 vials. Ok, I'll gather it all. Gee, wonder why there's only ten in this one? And only ten in that Pyxis? Man, I'm cleaning out ALL the Dilantin from the unit! Ok, have it all. Drawing up vial one.....four.....seven.....nine....gee, seems like alot of work. Drawing up vial 11.....17.....20.....24. Whew, this is taking ALOT of time! Never had to do THIS much Dilantin before. Never saw anyone else do this either. Oh, well....drawing up vial 27.....30....32! Gonna need two bags for this....and start another IV. Gosh, I hope I don't have to do this again in a few hours!"

Which is why I can't imagine a sober, non-impaired nurse doing this.

Exactly what I was thinking. No nurse, good, bad or indifferent, would have drawn up this amount if they were in their right mind. She had to have been under the influence of something and that maybe why she's not talking. If she wasn't, then she is too extremely stupid to be a nurse. I don't care how stressed or hurried you are, you MUST at all times, follow the five rights, no matter what!!!! There is no excuse for this error. I'm sorry, I don't feel anything but disgust for her, I do feel extremely sorry for the three children and the husband who now have to live without mom and wife. I agee that $200,000 seems like a low settlement in this case too, but maybe the hospital has some sort of cap or something. I don't know. I hope the Florida BON takes her license away for good so that she can never harm another patient. It's scary to think that there may be other errors she has made that no one caught. Sorry to sound so harsh, but this just hits a nerve with me. We nurses get enough grief without some moron making this kind of error and making us all look bad.

Pam

[firstaiddave907]

Originally Posted by MarySunshine

I don't understand what the doctor did wrong.

I have NO idea how she gave that much dilantin. That's makes NO sense.

I agree with you.