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by fedupnurse

A couple of months ago one of the endocrinologists wrote an order for insulin scales. One was for 8 am to 8 pm and the other was 8pm to 8 am. When I looked in the computer to sign off my 8 pm dose I saw 2 insulin scales but the pharmacists had put them in for 8p-12mn-4a and 9p-1a and 5a. Hello!!!! SO I called her and she said "I don't know how to change it in the computer." SO I said "So you are just going to leave it like that??" She said "yeah." SO I had to fill out one of the variance sheets and call the supervisor and tell my charge nurse. It was fixed before the end of my shift but still, how scary is that??? I can easily see this patient going all day without insulin coverage.
SO what errors have you seen and found before any harm was done to the patients?

[hoolahan]

I was helping a co-worker to prepare for line changes in the CT ICU where I used to work. We were running through the new IV's and tubings for a relatively unstable pt. My friend was about to hang the Inocor, for those of you who don't know, this is a pretty potent drug, it was a glowing yellow color in the bottle, very much like MVI. It had wicked side effects, and most pt's who were on it for any lenght of time would turn the same color as the solution, from liver dysfunction caused by this drug, which is why it isn't used any more. Anyway, this time I noticed the bottle, prpared by pharmacy, was not just yellow, it looked like betadine! I read the label, it said it was mixed with the diluent .45 NS, but I was sure there was no diluent in the bottle. Called pharmacy, they sent a RPh up, and sure enough, no diluent in the bottle. The pt's pressure probably would have bottomed out if we had hung that as is! That was, and still is, the worst error I ever caught.

[fedupnurse]

OMG!! Thank God you were on the ball Hoolihan! I hated Inocor! That stuff would get on you (we had to mix our own) and you'd be stained for life!
Great save!!!!!! Ever seen Nipride turn blue??????

[SOCRATES SOUL]

Errors?? Lets start with the blatantly obvious errors that reigns supreme and that being management and the administrators they haul on in to run the show, many who often havnt got a rats arse what really happens in the trenches and are too busy bean counting...

[caroladybelle]

One of our nurses spotted that the pharmacy sent up Hydroxyzine (Visteril) instead of Hydralizine (Apresoline) - the drug was to be given IVP.

One time, an MD ordered IVP Thorazine 50 mg. We have also had MDs order NPH insulin IV.

Perhaps the scariest was Vancomycin sent for Vincristine in IVPB form.

[Pharmacist Joe]

What errors have you caught? (Docs, Pharmacy, etc.)

As a pharmacist who has worked in hospitals for 30 years, I am grateful when a nurse catches a pharmacy error. But let's not get high and mighty, here. I've caught my share of killer nurse and MD errors, too. Face it: we are human beings and we make errors. Our hospital systems (for example, unit dose systems) are DESIGNED to catch the errors that humans will inevitably make in the complex environment of the hospital. So let's do our jobs, check each other, and protect the patient. If you catch an error, report it (reporting helps find systems problems and provides healthy feedback for the person who made the error). Be professional and patient-oriented about it.

Med errors is a fascinating topic. Check out www.ismp.org.

[catlady]

Unit dose systems aren't worth squat when it's the wrong medication being sent up by the pharmacy. I called the pharmacy one night because they had sent a similar-sounding--but wrong--antibiotic. Their attitude was "Oh, well, what's the big deal?" I think it would have been a big deal to the patient. If I had given that med, I would have been written up for the med error. Pharmacy (and lab, and doctors) never take the fall; always nursing, in my experience.

[fedupnurse]

Hey Pharmacist Joe,
Wasn't trying to get high and mighty about it at all. As Catlady points out though, nursing very frequently takes the fall. Case in point: A doctor forgets a decimal point on a chemo drug for a baby. 2 Pharmacists checked the order and filled the script and a nurse gave the med. The nurse by the way didn't usually work that unit. That is no excuse, I know, but the only one fired was the nurse. Of course she should have checked the correct dose, but come on when another dept screws up where I work it is usually the nurse that catches hell for it. My intent was to shed light on the topic because there are many people who use this board who are new to nursing and thought this might educate them.
Regards,

[SmilingBluEyes]

I will tell you a BEAUT! I ACTUALLY had a dr order me to OPEN wide a POTASSIUM drip in LR on a shocky 2 days postpartum patient. I said "let me get a bag of straight LR or Normal Na. He said "NO. Do this NOW!". I said clearly and calmly " I will NOT BOLUS Potassium!" He reached for the IV, and I grabbed his hand. Then, he seemed to realize what he was saying. Calmly Said, "yes, get some LR first" as if it was NO BIG DEAL! UGGGGGGGGGGGGGGGGHHHH. WE are the LAST stop in protecting our patients from harm--- It is TRUE! I was a new graduate nurse when this happened. I remembered my nursing instructors saying "WE don't expect critical thinking to be sharp for nothing....you will NEED it to save LIVES!" They were right on target there!

Since then, I have seen numerous things come by that I had to take corrective actions on, potentially harmful situations. We are human and make mistakes. I am fortunate in that the night nurses I work with and I are a "team", constantly helping and watching over each other. We have caught mistakes on and off for each other at times and thankfully, consider this our job.

Regarding patient safety, I think of the patient as my mom, sister, gramma, best friend, and treat her as such. It makes me pay close attention to the "five rights" of medication and also watch closely my practices when caring for them.

[fedupnurse]

Of course errors on the part of all health care professionals would be far less if all of us, nursing, pharmacy and lab, etc. had adequate staffing. I agree Smilin', thinking of the patient as a loved one does keep you on your toes. You said it perfectly-we ARE the last line of defense.