What errors have you caught? (Docs, Pharmacy, etc.)

hoolahan, ASN, RN · May 27, 2002

I was helping a co-worker to prepare for line changes in the CT ICU where I used to work. We were running through the new IV's and tubings for a relatively unstable pt. My friend was about to hang the Inocor, for those of you who don't know, this is a pretty potent drug, it was a glowing yellow color in the bottle, very much like MVI. It had wicked side effects, and most pt's who were on it for any lenght of time would turn the same color as the solution, from liver dysfunction caused by this drug, which is why it isn't used any more. Anyway, this time I noticed the bottle, prpared by pharmacy, was not just yellow, it looked like betadine! I read the label, it said it was mixed with the diluent .45 NS, but I was sure there was no diluent in the bottle. Called pharmacy, they sent a RPh up, and sure enough, no diluent in the bottle. The pt's pressure probably would have bottomed out if we had hung that as is! That was, and still is, the worst error I ever caught.

fedupnurse · May 27, 2002

OMG!! Thank God you were on the ball Hoolihan! I hated Inocor! That stuff would get on you (we had to mix our own) and you'd be stained for life!

Great save!!!!!! Ever seen Nipride turn blue??????

SOCRATES SOUL · May 27, 2002

Errors?? Lets start with the blatantly obvious errors that reigns supreme and that being management and the administrators they haul on in to run the show, many who often havnt got a rats orifice what really happens in the trenches and are too busy bean counting... :smokin: :nono: :uhoh3:

caroladybelle, BSN, RN · May 27, 2002

One of our nurses spotted that the pharmacy sent up Hydroxyzine (Visteril) instead of Hydralizine (Apresoline) - the drug was to be given IVP.

One time, an MD ordered IVP Thorazine 50 mg. We have also had MDs order NPH insulin IV.

Perhaps the scariest was Vancomycin sent for Vincristine in IVPB form.

Pharmacist Joe · May 27, 2002

As a pharmacist who has worked in hospitals for 30 years, I am grateful when a nurse catches a pharmacy error. But let's not get high and mighty, here. I've caught my share of killer nurse and MD errors, too. Face it: we are human beings and we make errors. Our hospital systems (for example, unit dose systems) are DESIGNED to catch the errors that humans will inevitably make in the complex environment of the hospital. So let's do our jobs, check each other, and protect the patient. If you catch an error, report it (reporting helps find systems problems and provides healthy feedback for the person who made the error). Be professional and patient-oriented about it.

Med errors is a fascinating topic. Check out http://www.ismp.org.

catlady, BSN, RN · May 27, 2002

Unit dose systems aren't worth squat when it's the wrong medication being sent up by the pharmacy. I called the pharmacy one night because they had sent a similar-sounding--but wrong--antibiotic. Their attitude was "Oh, well, what's the big deal?" I think it would have been a big deal to the patient. If I had given that med, I would have been written up for the med error. Pharmacy (and lab, and doctors) never take the fall; always nursing, in my experience.

fedupnurse · May 27, 2002

Hey Pharmacist Joe,

Wasn't trying to get high and mighty about it at all. As Catlady points out though, nursing very frequently takes the fall. Case in point: A doctor forgets a decimal point on a chemo drug for a baby. 2 Pharmacists checked the order and filled the script and a nurse gave the med. The nurse by the way didn't usually work that unit. That is no excuse, I know, but the only one fired was the nurse. Of course she should have checked the correct dose, but come on when another dept screws up where I work it is usually the nurse that catches hell for it. My intent was to shed light on the topic because there are many people who use this board who are new to nursing and thought this might educate them.

Regards,

SmilingBluEyes · May 27, 2002

I will tell you a BEAUT! I ACTUALLY had a dr order me to OPEN wide a POTASSIUM drip in LR on a shocky 2 days postpartum patient. I said "let me get a bag of straight LR or Normal Na. He said "NO. Do this NOW!". I said clearly and calmly " I will NOT BOLUS Potassium!" He reached for the IV, and I grabbed his hand. Then, he seemed to realize what he was saying. Calmly Said, "yes, get some LR first" as if it was NO BIG DEAL! UGGGGGGGGGGGGGGGGHHHH. WE are the LAST stop in protecting our patients from harm--- It is TRUE! I was a new graduate nurse when this happened. I remembered my nursing instructors saying "WE don't expect critical thinking to be sharp for nothing....you will NEED it to save LIVES!" They were right on target there!

Since then, I have seen numerous things come by that I had to take corrective actions on, potentially harmful situations. We are human and make mistakes. I am fortunate in that the night nurses I work with and I are a "team", constantly helping and watching over each other. We have caught mistakes on and off for each other at times and thankfully, consider this our job.

Regarding patient safety, I think of the patient as my mom, sister, gramma, best friend, and treat her as such. It makes me pay close attention to the "five rights" of medication and also watch closely my practices when caring for them.

fedupnurse · May 27, 2002

Of course errors on the part of all health care professionals would be far less if all of us, nursing, pharmacy and lab, etc. had adequate staffing. I agree Smilin', thinking of the patient as a loved one does keep you on your toes. You said it perfectly-we ARE the last line of defense.

willie2001 · May 27, 2002

Are you kidding! Our pharmacy never makes a mistake!:roll

cbs3143 · May 27, 2002

Several years ago, we had an ER "Rent A Doc" with "Impeccable Qualifications" was writing admit orders when I came out of report. One of the orders that I watched him write was for Coumadin 300mg P.O., I kid you not. I asked him if he was sure that he wanted to write that dose. He then asked me what the normal dosage was. I told him it was between 2.5 and 10mg. He later had a patient with a severe headache who had been seen in the ER the previous day ane was discharged with a Vicodin and Valiun combination that wasn't helping that day. The same Doc ordered a repeat of the Vicodin and Valium and one of the other nurses suggested some Demerol and Vistaril instead. He asked, "What's Vistaril?" We were thinking OMG. We let the supervisor know what was going on and were advised to keep an eye on him. He later asked me about writing a prescription for Tylenol #3, and I told him to make sure he wrote his DEA # on it. He then asked me if it had Codeine in it. I couldn't believe this guy and was calling the supervisor again. That was one of my scariest shifts ever. When he was fired the next day, he was livid that someone had questioned his judgement. I could only think, what judgement?

Another error occurred when one of our regular ER Docs wrote an order for Vistaril 50mg IV. I told him that I couldn't give Vistaril IV, and he added two ink marks that perfectly changed the IV into an IM. It was good for the patient, but it also struck me how easily I could have been hung out to dry if I'd given the med IV, had problems, and them come back to find the chart changed to IM. Fortunately that never happened.

We are frequently the last line of defence for our patient's safety.

Chuck