S. O. S.

RNPD · Mar 1, 2002

"I gave 25mg of Dilaudid to an elderly patient instead of 25 mg of Demerol that was ordered"-Renee Williams

"...reaching for the Demerol, and picked up the Dilaudid instead."-Brownie

25mg of DILAUDID?? Are you sure? 25mg of demerol is a fairly light dose-25mg of Dilaudid would probably KILL a person!Dilaudid comes up to 4mg/ml injectable and 4mg po, or 3mg suppository. So how could you give 25mg by mistaking one Dilaudid syringe for a demerol syringe?

Alos would like to add that marking the beds is a good idea. My new job has the A bed near the window, the B bed near the door-exactly opposite of my previous job. Have so many times said to someone 260A when I meant 260B. Of course the best way to avoid a med error in this case is not to give the B bed's meds to the person in what you think is the B bed, but rather to check the armband when giving meds to each patient so as to ensure you have the correct patient!

Fran-RN · Mar 1, 2002

I work in long term care and was giving meds to 2 ladies at the dinner table one night. one was alert and oriented the other was very confused. I was getting ready to hand the alert one her cup of medications, when a fight broke out across the room. not thinking. I set the pill cup down and went to break up the fight. when I returned, the confused lady was setting the pill cup down on the table. I panicked. I started whacking her on the back and yelling "spit that out!" luckily, she hadn't swallowed them yet. not one of my finer moments in nursing. but we are all distracted at one time or another and we all make mistakes. no harm came to this resident, not even from the beating i gave her while trying to get her to spit out the meds. lol

Brownms46 · Mar 1, 2002

Dear RNPD,

Please forgive me for the confusion. When I stated same med, same dosage...I was referring to the Demerol dose. As I stated in my error while reaching for Demerol I picked up the Dilaudid. No where in there did I state Dilaudid 25mg was given by me. I didn't even pay attention to the the dose of Dilaudid Renee said she gave and neither did a couple of other posters, including one who also quoted the post. What I was focusing on was we both gave the Dilaudid for the same Demerol Dose. ...and that we had the same events afterwards. Sorry didn't mean to confuse anyone. In my mind I was focus on the event. For me this happened 21yrs ago, and I was sure I had did the dumbest thing ever. So when I saw Renee post the same Drug error...I was amazed.....and although it was an error that shouldn't have happened...I wasn't the only one who did it.

You are absolutely correct that there was no way I could give Diluadid 25mg to a pt with one syringe, and I know Renee didn't either, as neither pt. had any adverse effects,.... and as we all know that Diluadid only comes in 1mg/1ml sol./4cc dose syringe. And yes it does come in 4mg tabs, and 3mg supp...but also in 2mg, 8mg tabs and 1mg/5ml syrup.

But I guess we all miss things...as I also posted:

"No matter where I go ...I take the med sheet with me to the room and check it against the pt's. ID band so I KNOW I have the right pt. If I'm in a facility where everything is on the pc, I print out a list of the meds for each pt. "-Brownie

And you posted -RNPD

"Of course the best way to avoid a med error in this case is not to give the B bed's meds to the person in what you think is the B bed, but rather to check the armband when giving meds to each patient so as to ensure you have the correct patient! "- RNPD

But making errors, and reading carefully was the whole point of the posts here.

To you RNPD, and all whom I may have confused...sorry I made the error of not being clear about what I was thinking in my posts. :cool:

live4today, RN · Mar 1, 2002

TO RNPD:

GEEZ! YOU KNOW YOU ARE ABSOLUTELY RIGHT ON THE DOSAGE OF DILAUDID! :eek: Thanks for the correction, RNPD! :) I had to go look it up just now in my PDR, and lo and behold, Dilaudid does only come in 2-4mg tubexes for IM or IV injection! I stand corrected. Thanks again for being on your toes here!

So, what I gave, and what Brownie46 may have given was Dilaudid 2mgs. in place of the Demerol 25mg IM dose. Why, that's certainly a relief! That could be why the doctor didn't blow my head off! He just smiled at me, and calmly said, "That's okay. She'll just sleep it off, and be no more the wiser."

Of course that did not make me feel any better! :mad: I was so upset with myself the entire day, and I practically gave that elderly patient one-on-one bedside care throughout the rest of my shift, checking her vitals more than I would normally have, and was so relieved when she finally woke up and smiled at me, started chattering her head off (as she was prone to do), and speaking very coherantly with her family who arrived shortly before she woke up. They were never told since no harm was done, but I still wrote up the incident report, and the risk manager talked to me about "the 5-Rs".

Even though it is a scary thing to make a medication error that could end up costing a patient their life, medication errors are bound to be made. I just thank God that the med errors I was responsible for making did not cause any harm to my patients at that time of learning in my life. :)

BTW, the Nurse Manager made a rule that Demerol and Dilaudid could no longer be kept side by side in the med drawer to prevent errors like that in the future. Apparently, a few other nurses told her they had done the same thing I did in mistaking the boxes as the same because they were identical to one another. If nurses weren't so rushed in their work, less errors would occur, don't you think?

Brownms46 · Mar 1, 2002

Geeze Renee...I just looked it up too...and found Dilaudid comes in a whole host of different dosages including but not limited to 1mg/ml, 2mg/ml and 4/mg/ml: and a 20ml multi-dose vial:eek:

Thanks for trying to help my mistake not look as bad...but I guess our similarities end here...I gave the whole 4mg! So my screw up was even worse...as you gave the lesser or the usual dose of 2-4mg, and I gave the greater amount:eek:!!! I'm just glad that both our pts had no adverse reactions...THANK GOD!!!

Here's to always being more careful in everything we think, say, do, and post! :cool:

RNPD · Mar 1, 2002

Thanks to Renee & Brownie for clarifying. Obviously, the lesson to be learned here is to check the med as you remove it, as you prepare it, & as you put the container away, or throw it away.

Of course we all make errors. My biggest one that I recall was giving Vanco IV instead of the ordered po when i was a new nurse. Had never seen it given off label as po and for some reason read the order 2 or 3 times and saw IV. I guess the mind is a funny thing and sometimes you "see" what your mind expects to see. In spite of numerous warning signs, including the patient telling me he thought the doc had stopped the IV the day before, I still went ahead & gave it. Then I thought to ask the nurse from the day before if she had any trouble giving the pt the vanco & she said, "no just mix it in OJ". Talk about your heart sinking! Well no real harm done, the pt was getting it iv until the day before and so missed one oral dose. But that scared me enough because it COULD have had serious consequences. I refuse to hurry thru meds anymore.

RNPD · Mar 1, 2002

Forgot to ask Brownie-the 20ml vial of morphine-how many mg/ml does it hold? Never saw one and would imagine them to be VERY dangerous as opposed to unit dose-not to mention easy to tamper with. Also never saw an 8 mg po dose-is it new?

Also, when I said it comes up to 4 mg IV and po, I didn't mean to imply it was the only dosage. We carry 1mg/ml & 2mg/ml IM/IV or 1mg and 2 mg tabs. I personally have never seen any other dose and was going by my drug book. It didn't mention multidose vials there, but it is an OLD book! I need a new one!

live4today, RN · Mar 1, 2002

RNPD, in my new PDR, it does mention a 20ml multidose vial of Dilaudid. Thanks for your reply!

Brownie, we would have both caught that one and known it would have been too much! We would have, wouldn't we? :) Of course, let's not even entertain that thought! Now, that would have landed us both behind bars had we given that much dilaudid! We might be cell mates, eh?

We can make light of our mistakes, but the serious nature of making serious medication errors is certainly Never to be taken lightly! And, I never would, and never have!

____________________________________________

"Good judgment comes from experience, and often experience comes from bad judgment." -- Ashleigh Brilliant

RN-PA, RN · Mar 1, 2002

I made a stupid-- no excuses --med error in the last year involving insulin. The patient was a post-op and I was rushing around during a typically hectic evening. I unfortunately read the patient's insulin order off of the med kardex (rather than from the chart-- I know. I know.) which had been sloppily copied by a Unit Clerk notorious for bad handwriting. (I know. I know. More reason to double-check.) I read "Insulin, 40 units 70/30, SQ q p.m." and administered it after doing a fingerstick to check her blood sugar and after she'd eaten dinner. Problem was, the order was for "Insulin, 4 units 70/30 SQ". On the kardex, it appeared as, "Insulin, 4u 70/30 SQ" with the "u" looking like a "0". .. and I saw "40".

The House Doctor was called, came up and wrote orders for stat D50 and asked to see the kardex with the order. He said, "What's the problem? It says Insulin 40 units 70/30 here." I showed him the order in the chart and he proceeded to reassure me like crazy that anyone would've read that wrong. The attending M.D. was contacted and also reassured me, "We all make mistakes" and was very kind, but nevertheless, I was beating myself up and deserved any stern rebuke they could've given me; I wrote the incident up, and the poor patient had to endure q1h Accuchecks through the night due to my mistake.

Yes, I learned a hard lesson that I pray I won't ever repeat, but we are all human and make errors at times. It can be dangerous when things get so chaotic and busy, but it's vitally important to stay focused and calm in the midst of the storm. Some nights I'm amazed that MORE mistakes aren't made... :imbar :stone :imbar My husband has said, "You can't be perfect-- Nobody is!" But my response is always the same: "This is one job where you pretty much HAVE to be perfect." :stone

Brownms46 · Mar 1, 2002

Dear RNPD... :cool: ,

Yep...your drug book must be an OLD one..lol...because the multi-dose is 2mg/20ml!! Now with that we could have given 25mg!!! :eek: :eek:!!! and liq can come in as much as 10mg/ml. Also tabs come in 1mg, 2mg, 3mg, 4mg, and 8mg. Powder for injection can come in a 250mg/vial!!! Geeze would have hated to have got hold of that bugger! :eek: !!! Lordy

Geeze aren't we lucky...they didn't have all this stuff in that old med cart!! WWHEEEWWW!

mattsmom81 · Mar 1, 2002

I think the public must be made aware of the fact that med errors are increasing with poor staffing ratios and insufficient internships/supervision of new grads. Hospitals should be held accountable for their poor staffing practices. Hospitals are trying to hide that fact behind a smokescreen..they say "Oh, nurses have always made mistakes, they just covered them up for years and now they're documenting more." I've caught some doozies of med errors in the past few years where I have been fortunate to prevent the deaths of patients...only my years of experience prevented tragedy. We must be scrupulous with meds. And yes, we all make mistakes (being the humans we are) but we must never let this issue become blase. Unfortunately I have worked with those who do...and the mistakes continue. We have to be hard on ourselves and learn from our mistakes. I'll get off my soapbox now!

Brownms46 · Mar 1, 2002

:eek: :eek:

DAWG GONE IT....RENEE....GET OUT OF MY HEAD...pleeze..LOL!

As I was responding to RNPD...I was thinking...GOD if we had given that much...we would have been on the news...and in jail.. :eek: :eek:!!!

All I can say is Thank you Lord...for saving our PTS. FIRST...and OUR NECKS SECOND!!:imbar :imbar