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by Cindy-san

I got this pt last night. Comatose, DNR, on pressors but as per the family, the doc's changed the parameters of the DNR so we're not to increase the pressors if the blood pressure decreases.

The blood pressure had been pretty marginal but in the middle of report (of course) it starts to fall further. I go in there and the MAP is 39-40. PA calls the family.

I take a look at my drips and there's Levaquin hanging instead of Levophed.

I guess the previous nurse didn't realize Levophed isn't the only med that comes in a "protect from light" brown bag. But that's still not an excuse for this nurse to not look at what they were hanging. Pharmacy will send you weird things. I've had meds labeled by the company (like Levaquin) mislabled at my old job (Pharmacy thought it was Flagyl).

Needless to say, pt survived my shift.

[TazziRN]

Re: Er, let's watch what we're doing here, ok? Thanks

Good Lord...........

[cursenurse]

Re: Er, let's watch what we're doing here, ok? Thanks

Originally Posted by Cindy-san

I got this pt last night. Comatose, DNR, on pressors but as per the family, the doc's changed the parameters of the DNR so we're not to increase the pressors if the blood pressure decreases.

The blood pressure had been pretty marginal but in the middle of report (of course) it starts to fall further. I go in there and the MAP is 39-40. PA calls the family.

I take a look at my drips and there's Levaquin hanging instead of Levophed.

I guess the previous nurse didn't realize Levophed isn't the only med that comes in a "protect from light" brown bag. But that's still not an excuse for this nurse to not look at what they were hanging. Pharmacy will send you weird things. I've had meds labeled by the company (like Levaquin) mislabled at my old job (Pharmacy thought it was Flagyl).

Needless to say, pt survived my shift.

Yes I have heard of that happening with the levophed and levaquin. that's why even in emergency situations, take the time to read the label carefully. I wonder how long that levaquin was hanging, because outside of a code situation, don't folks routinely double check the pump, and the fluid/med that is hanging when they go into the room to check the patient. I wonder why that wasn't caught. I hope you wrote an incident report on that one, cause that was bad. Good for you for being dilligent about not just taking her word for it, the pt probably would've died.

[MedicalLPN]

Re: Er, let's watch what we're doing here, ok? Thanks

Wow.... It's amazing that patients survive some of the things we do to them.

[ernurse93]

Re: Er, let's watch what we're doing here, ok? Thanks

I was always afraid of levophed, because we have to mix our own cardiac drips. That made me nervous. Now I'm glad we do. That is scary. Glad your patient survived.

[canoehead]

Re: Er, let's watch what we're doing here, ok? Thanks

Well, she won't be needing blood cultures this shift...

[Sue Damones]

Re: Er, let's watch what we're doing here, ok? Thanks

Wait a sec... isn't levaquin yellow in color? And I've never seen Levophed come in a "protect from light" brown bag. Only Nipride and some other abx...


I'm confused

[nrsang97]

Re: Er, let's watch what we're doing here, ok? Thanks

I have never seen either in a protect from light bag. Levaquin is yellow and Levophed is not. How the heck do you get them mixed up?

[Cindy-san]

Re: Er, let's watch what we're doing here, ok? Thanks

Originally Posted by Sue Damones

Wait a sec... isn't levaquin yellow in color? And I've never seen Levophed come in a "protect from light" brown bag. Only Nipride and some other abx...


I'm confused

I had seen the bag on occasion at my old job for both of those meds, but it's used all the time at my current one. I was trying to figure out why but every ref I find says "protect from light" in reference to the med while it's in the little bottle.

Originally Posted by nrsang97

I have never seen either in a protect from light bag. Levaquin is yellow and Levophed is not. How the heck do you get them mixed up?

Our light bags are brown semi-transparent plastic bags which covers the whole med bag, the previous nurse had just grabbed the whole thing and hung it, assuming it was Levophed. I almost fell over when I saw the tubing was that yellow-green color.

Personally, I'm more suprised they didn't notice based on the size/weight diff. Levophed is 250ml, more than twice the size of those little Levaquins.

[GrumpyRN63]

Re: Er, let's watch what we're doing here, ok? Thanks

I once had pharmacy send me a bottle of nitroglycerin in place of multivitamins- they use to be dispensed in the exact same brown bottle with red rubber stopper, could have killed her. Another time they sent me prostin suppository (labor inducer) instead of progesterone suppos for an IVF pt who was just successfully pregnant after years of infertility.. ALWAYS READ THE LABELS, no matter how familiar you think you are with packaging