What would you have done?

  1. A co-worker was caring for 2 patients who were being treated with the same drug (cytoxin) but one of the doses was twice the amount of the other. She started both infusions within minutes of each other. About halfway through the infusions she realized she had mixed up the doses, so that patient A was receiving twice the ordered dosage, while patient B was getting about half the dose. She immediately told the physician what happened, and his resolution of the mistake was to stop the infusion on patient A and infuse the remaining amount into patient B. No, I am not kidding. I'm not sure which stunned me more, his idiocy or my co-worker who didn't bat an eye and actually started to do what he told her to do. *****???? I went ballistic and told the doc no way, no how, was this going to happen under my watch. After 5 minutes of screaming at each other he finally walked away in a huff, mumbling that I could do whatever I wanted. Just as well, because I was ready to call in the calvary and I think he knew it.

    How would you have resolved this?
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  2. 20 Comments

  3. by   LT Dave
    I would have told him, matter of factly, that we will not be doing that at all. If he insisted ask him to write it as an order...which only an idiot would do. No need to fight about it with him. Never do anything you are against or fight about it when you have a Supervisor to call. Let them deal with it. You did do the right thing, also educate that nurse who is under you.
  4. by   AcosmicRN
    OK. I don't get it, because it sounds like it mathematically works out.

    two clients get the same drug
    One client gets twice as much as the other
    half way through it is realized that the drugs were switched
    That would mean that client A has gotten the right dosage, but client B has only gotten half the prescribed dosage, what is remaining is the other half that belongs to client B, so why not give it to client B and everything comes out in the wash?

    Of course this assumes that both doses are of equal concentration, but the "double dose" for client B is in a larger volume of dilutent, say 500 ml instead of 250.

    OK, so school me.

    Acosmic
  5. by   P_RN
    About half way and about half a dose aren't enough. My plan would have been to ask for another 1/2 dose for the one who got half. That's a definite, and he will get the correct dose. The other patient B needs more but the quantity is in question. The doctor would have to use his judgement in either holding the rest of the dose or estimating what that would be and giving it. It's unbelievable he would think just switching bags or syringe (GASP!) to another patient would be safe or legal.
  6. by   gizelda196
    Well ,first of all cytoxin ,I believe is a chemotherapeutic agent. People die from drug errors.Never mind the problems with toxic levels of chemo. Secondly, you cant just switch bags! They would be contaminated and never mind the blood Bourne pathogens. You just don't do that!. The patients rights where broken.(route,time patient, dose,drug)
    An incident report should have been created stating the all the facts.The supervisor should have been immediately called. and a quick email to the chief of medicine regarding the Doc should have been sent.I can't even believe the Doc(well really yes I can) Document every thing. Next time,agreeing with the previous poster, Don't argue .Just refuse and call the nursing supervisor that's why they get the big bucks .
  7. by   pghfoxfan
    The way I took the post above was not that the doctor said to stop infusing the one persons med and switch it, but to just finish the one hanging. No one would allow cross contamination. But, I have been a nurse 22 years, and I still would not have made a big deal out of this. First off and most important, the patient wasn't harmed(or at least the poster did not say this). Second, nurses "eat their young". If this was not a person that repeatedly makes med errors(and again the poster did not mention this), I would let her learn from her mistake, and TRUST ME, we have ALL made mistakes and we DO learn from them.

    I Commend nurses for staying in the hospital setting when there is such a nursing crisis and the work is so difficult. All too many nurses are taking these "phone insurance" type jobs, or jobs that take them out of the patient care setting for that perfect M-F daylight job, leaving hospital nurses critically understaffed and over worked. We should be saying Thank God you still want to work in a hospital setting, and cut them a break if a error happens (that does not harm the patient).

    We need to be supportive of each other. We need to remember what it was like when we were just starting.
    We need to remember that we are only human.

    If we had enough nurses to go around, and we weren't so busy doing JCAHO paperwork ****, we could give the patient care that we were taught.
  8. by   rn4booboo
    I agree- I really didn't see the big deal and would have possibly not batted an eye. There was no bag switching, and the patient B got half his dose- perhaps the doc will add another one later- Patient A got double the dose but only recieved half. Where is the major malfunction here. I would probably have the dr in writing sign off on this- since later it wouldnt be your ***- but I bet the nurse learned from this too. Just tell her thank God it wasn't something else (ie different drugs etc.)
  9. by   canoehead
    I think that cross contamination would not be an issue unless the bugs managed to crawl all the way up the IV tubing and into the bag. I'm assuming that you would change the tubing before infusing the med. Certainly not something to do as a regular practice because of errors possible, but in a one time situation and with a docs approval....

    Of course if he is at the bedside, and you are uncomfortable, just tell him it's not regular nursing practice, would he mind doing it.

    BTW nothing is worth a screaming match-walk away.
  10. by   loerith
    Quote from pghfoxfan
    The way I took the post above was not that the doctor said to stop infusing the one persons med and switch it, but to just finish the one hanging. No one would allow cross contamination. But, I have been a nurse 22 years, and I still would not have made a big deal out of this. First off and most important, the patient wasn't harmed(or at least the poster did not say this). Second, nurses "eat their young". If this was not a person that repeatedly makes med errors(and again the poster did not mention this), I would let her learn from her mistake, and TRUST ME, we have ALL made mistakes and we DO learn from them.

    I Commend nurses for staying in the hospital setting when there is such a nursing crisis and the work is so difficult. All too many nurses are taking these "phone insurance" type jobs, or jobs that take them out of the patient care setting for that perfect M-F daylight job, leaving hospital nurses critically understaffed and over worked. We should be saying Thank God you still want to work in a hospital setting, and cut them a break if a error happens (that does not harm the patient).

    We need to be supportive of each other. We need to remember what it was like when we were just starting.
    We need to remember that we are only human.

    If we had enough nurses to go around, and we weren't so busy doing JCAHO paperwork ****, we could give the patient care that we were taught.
    I couldnt possibly agree more.

    "Nurses eat their young" is just a nice way of saying that many of them are backstabbing, tattling rats.

    Someday {though I doubt it} perhaps nurses will wake up and realize that if we spent as much effort sticking together as we currently do ratting each other out, nursing would be one of the best professions in the world. It should be:

    "I have your back."

    not

    "Here comes the knife."


    Love and Peace,
    loerith
  11. by   Dixiedi
    Quote from AcosmicRN
    OK. I don't get it, because it sounds like it mathematically works out.

    two clients get the same drug
    One client gets twice as much as the other
    half way through it is realized that the drugs were switched
    That would mean that client A has gotten the right dosage, but client B has only gotten half the prescribed dosage, what is remaining is the other half that belongs to client B, so why not give it to client B and everything comes out in the wash?

    Of course this assumes that both doses are of equal concentration, but the "double dose" for client B is in a larger volume of dilutent, say 500 ml instead of 250.

    OK, so school me.

    Acosmic
    Forget the math! Are you willing to take a bag from one pts IV pole and hang it on anothers? I'm not even talking about plugging it in yet! I'm talking about taking a contaminated item from one bedside to use at another bedside!
  12. by   pghfoxfan
    OK...I totally missed it where she said that someone switched bags? I am NOT talking cross contamination here! That is a total WTF moment! I am saying if the nurse took down the ones bag and continued the other persons bag. And I agree, Nurses out # doctors and almost any other profession. If we stuck together, look and see how many good things we could do together. Look at the people we could vote into office. Nurses need to UNITE!
  13. by   Dixiedi
    Quote from Dixiedi
    Forget the math! Are you willing to take a bag from one pts IV pole and hang it on anothers? I'm not even talking about plugging it in yet! I'm talking about taking a contaminated item from one bedside to use at another bedside!
    I took the "infuse the remaining amt" as being the bag from the woman who was getting the higher dose to "share" the bag with the lady who should have gotten the higher dose. 1/2 the bag would be approximately her dose. She would theoretically be medicated (assuming both bags were same volume).
    The other woman, who needed the "stronger" dose would then have gotten 1/2 from the lower dose bag and 1/2 from the larger dose bag. Theoretically they would then both have had their corect dose. ALL THINGS BEING EQUAL, but... it would have been a contaminated dose!
  14. by   caroladybelle
    Cytoxan is a chemo drug.

    What hospital these days, doesn't require double checks (two nurses) at the bedside for a chemo check?

    JCAHO would have a field day.

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