Some Med Errors

[ellakate]

We all wonder what would happen if. . . .something happened and you made a med error. Below are two that I remember all too vividly. Both patients recovered in spite of me.

When I was in nursing school, I worked as a pharmacy nursing technician in a Unit Dose system. One night I gave a patient his medication and used the clear liquid at his bedside. It was unlabelled hydrogen peroxide! The physician had me insert a nasogastric tube and aspirate!

Then there was the evening that I had a very anxious patient. She had an impressive psychiatric history and was post-op abdominal surgery. Her physician ordered IV buspar. The pharmacy filled the Rx with bumex, a potent diuretic, which could be given IV. And I did just that. I watched her face as I gave the medication, expecting to see her relax. Instead, she said, "I have to pee!" But she was much less anxious.

[scg08rn]

I once gave a patient sotalol 240mg when the scheduled dose was 160mg. The pharmacy sent a box of 40mg and 120mg and I pulled out two 120mgs, don't remember where my mind was at that time, I always check x3. That's my one and only *knock on wood* med error after 13 months of nursing! They were okay after close monitoring.

We all make mistakes, we are human afterall.

[CASTLEGATES]

Prefilling cups in nursing school and giving meds with my instructor to 50 patients...I said "Mr Smith" and a guy sitting on the bed said "Yes" I gave him his meds and Mr Smith walked up to the cart and asked for his meds. it was his roommate. I failed to check armbands.

On about these prefilled cups...my instructor proceeded to make an error that day, as well. Luckily both were abx and they weren't allergic.

Prefilling meds is dangerous; even my instructor gave the wrong one. It bypasses the R's when you don't know what's inside.

Oh....procedure error. I looked over the shoulder of the clerk and saw an order on my patient "remove NG tube" so I did after explaining to the patient "the doctor ordered it" failing to think WHY (which is why I take it upon myself to know every MD decision and why and learn what they know best I can)...

After pulling the tube, something didn't feel right and I went back to the chart where the clerk was taking the paper out and putting it in a different chart. She said "oops, wrong chart". I failed to read the stamper at the bottom (only looking at the chart).

He was a gastric surgery patient who NEEDED the NGT so anesthesia had to put it in. Nevermind it had a suture in his nares (I was so stooopid)! Just out of orientation, I was everyone's worst enemy...little knowledge and knew everything. Couple errors like that makes you grow up.

so.... I freaked, offered my badge, asked him to write me up...he said "it's bad, really bad but we'll move on from this".

[getoverit, BSN, RN, EMT-P]

In the middle of a code I was pushing high dose epi, 3mg. Still doing CPR and a few minutes later went to give 5mg (this was in the mid-90s), I pulled the plunger on the syringe and could only get 2cc out of the bottle. That's when I realized I had given 60 mg Lasix instead. Both were dark brown vials and sat fairly close to each other in the crash cart. I thought I was going to barf but the MD said it didn't make any difference because the dose of epi was only delayed by about 3 minutes and the patient had been defibrillated twice during that time anyway. Still I felt terrible.

[teeniebert, LPN]

We all know that you're never supposed to mix Lantus (insulin glargine) with any other insulin, right? Well...

A couple nights ago, I was drawing up a resident's bedtime insulin. I had to give sliding scale coverage so I had 2 syringes out--1 for Novolog, 1 for Lantus. I drew up the Novolog, then drew up the Lantus and was about to go into the room when I realized I only had 1 syringe in my hand. The second syringe was sitting on the med cart, still in its package. I had injected 25 units of air and 3 units of Novolog INTO THE LANTUS BOTTLE, then drawn up 28 units of now-useless mixed insulin. I felt so stupid! :selfbonk: I had to get another bottle from the backup supply and start again. The thing that made me feel worst was that the Lantus had only been open a few days and I had to waste an almost-full bottle. My co-worker got a really panicked look on her face when I told her about my mistake, then had a good laugh at my expense once she was sure I hadn't GIVEN the mixed injection.

[Meriwhen, ASN, BSN, MSN, RN]

An order for a blood pressure medication was increased but the prior nurse never discontinued the old one in the MAR. As a result I gave two doses of the pressure medication. My bad in that when pulling his meds, I should have questioned why this person was receiving two different doses of the same antihypertenisve.

However, the patient benefitted in the end: his BP had be running very high and after my mistake, it was finally WNL for the first time since he was admitted. I and my charge nurse reported this to the doctor and told him that we finally were able to control his pressure, and he agreed that the patient needed the higher dose and rewrote the order for the dose I had accidentally given him. They ended up upping it even further a few days later.

The mistake still upset me because I know I won't always be that lucky, so I've gotten into the habit of questioning myself about each drug and why the patient is getting it.

[trimm]

I had a med aide one night (don't usually get one) and she popped the coumadin from the wrong day in the cassette. I was checking the cart, saw the pill still in the slot for the correct day and gave it. Called the doc, got it fixed. It is soooooo easy to make a med error.