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.
Mar 25, '03
The off label use suggestion is intriguing.
It's hard for you knowing that something like this happened. It sounds as if you have done everything correctly.
The results of the investigation may be shared with the staff to help understand how and why it happened.
Last edit by P_RN on Mar 25, '03
Mar 26, '03
Thank you all for your comments. You all make great points that the higher ups now need to follow up on it. It is just really bothering me that this incident happened at all and I guess I wish that I could fix it all b/c first off the patient's life is in jeopodary and secondly I do feel for this nurse.
This just happened yesterday so I dont even know if the nurse yet knows. That being said, and due to the fact that it may become an issue, I cannot elaborate too much more. I apologize for the mystery. However, I can say this...as a nurse on our unit, a ccu we deal with the med on an everyday basis. The rationale behind using the med was different than our typical CCU patient but this patient was not a typical cardiac patient. However, the meds use still quite common for this patient type. (pt was different than our typical patient type but still any CCU or ICU "Prudent/educated" nurse in our environment should know what to do with the med and the patho to understand why we were doing what we were doing. It is something that we commonly use...commonly titrate...but only to maintain the med to be therapeutic.... with this particular pt... titration was not necesarry...only a low dose.. ... our orders are placed into the computer before pharmacy brings them over... the order was clear to run at a specific dose and made no mention of titration.
BTW....this person has been a CCU nurse for much longer than I have...so no...not new nurse or new to CCU
Last edit by New CCU RN on Mar 26, '03