I think I made A Med Error - page 2

by RaziRN

4,020 Views | 13 Comments

I had a patient the other night who had IV depakote ordered for 24 hours. I checked the pyxis and the patients medication bin and there was no IV depakote to be found. I even checked the main pyxis which has most of the meds.... Read More


  1. 0
    Especially with this type of medication, if it is something that your facility would send in IVPB form, your pharmacy will send it as it's suppose to be sent. Depakote is important, yes, but it is not a life saving medication. What you effectively did by calling the house supervisor for the med is circumventing EVERY failsafe in the hospital system, period.

    The only thing I have to say is since it is a med that is x24h, it's obviously prophylactic. That said, wait for pharmacy. If you're unsure of the med, a pharmacist is always a phone call away (or you have your guidelines, drug manuals, etc).
  2. 0
    I dont understand.HOw did physician write an order? PO? IVP? IvPb? phyicians should be specific about route of delivery, not to let nurses decide. When the pharmacy send medicine, they usually write specific instruction about delivery of medication, like depakote PO every 12 hours or depakote IVPB every 12 hours. If physician didnt write route, then you probalbly need to call the physician to clarify the order
  3. 1
    Ms. RN, the order read: Depakote 1000 mg IV q12h x 24h. Pharmacy usually does write out the rest on the MAR. Such as: infuse over 1 hour at 50ml/hr or what have you. However, this order was hand written on the MAR by the secretary as is common practice in our hospital. I don't know if it's like this elsewhere. It was written exactly as the physician had written it.

    As for other posters, it was the charge nurse who suggested I call the house supervisor. In fact, she was the one who called and then handed me the med when it came up. I'm not at all saying it was her fault or passing the blame. I'm just stating this for clarification. Calling the house supervisor for a med that needs to be given but isn't on the floor is also common practice at my hospital. I've had IV vancomycin brought to me from ICU. I mixed that with D5W and infused it over one hour. It was a case of not being familiar with a med and feeling rushed to provide patient care before my new admission (which was my 7th patient) got to the floor. We do our own admissions. I know I made a mistake. I took the necessary actions to own up to it and I've learned something. I really see no further reason to criticize me. I'm sure every one of you has made a mistake at some point or another. I'm only five months in, I have a LONG ways to go in terms of learning. I appreciate the replies that I've received that have been constructive. I'm actively seeking employment elsewhere, as I don't perceive the facility I'm working at to be safe. You just can't provide quality care with 7 patients, especially as a new grad.
    GooeyRN likes this.
  4. 0
    Don't beat yourself up. You made a mistake. I haven't met a nurse who hasn't made one. Thankfully, the pt wasn't harmed. You learned. You won't do that again. We also call someone to get us the med if it is not available. We do our best to give meds that are scheduled for a certain time. If we can't get the med, we have to call the doc and request something that we CAN get. So I don't look down on you for calling around to see if you could get the med to give as scheduled. You did the right thing by reporting your error to the charge/sup. You know better now to look something up quick if you aren't familiar. 7pts is a lot when you are a new grad (one being an admit), I understand how it happened.


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