Without going into much detail because of privacy issues, the other day I followed a nurse who made a huge med error which I discovered. It did cause a potentially life threatening adverse reaction. I notified my manager, risk management, and of course the physicians.
I guess I still feel like more should be done in order to avoid this problem again. It was a mistake as a result of not understanding the rationale behind a therapy we were giving the patient. Rather than consulting the MD, she took matters into her own hands and assumed a dangerous drip should be titrated.
If you were in this situation... what else would you do? Is there anything left for me to do?
I am heartbroken particularly for the patient bc he was beginning to turn around and start to improve and this mistake may cost his life.