IV drip dose error - page 3

by babbu

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I work in an ICU setting in the nights. My patient who is intubated was on a Fentanyl drip at the rate of 150 mcg, for the whole shift. Just at the end of the shift since I had to turn my patient i increased the dose to 200mcg.... Read More


  1. 0
    Quote from BrandonC
    I agree, ALL medication error is a big deal! Just be careful next time and learn from your mistakes.

    Definately agree! Once I thought I'd given too much of a medication for some reason (there wasn't even more than the intended dose in the vial!! haha), and I was sweating bullets until I realized there was no way that could have happened.

    Please PLEASE freak out over this small one and let it be your only one, since no harm came to the patient. It's really scarey when people act like it's no big deal (probably just trying to make you feel better, which is kind) because it COULD have been something much worse. This is a good little wake-up call for you. We've all made an error, small or large, or will and it should freak you out. It's truely scarey when people act like a med error or near miss is no big deal.
  2. 0
    Quote from babbu
    I work in an ICU setting in the nights. My patient who is intubated was on a Fentanyl drip at the rate of 150 mcg, for the whole shift. Just at the end of the shift since I had to turn my patient i increased the dose to 200mcg. After I finished turning him etc.. I meant to go back to the original dose that was 150 mcg, but I was in a hurry and I accidentally put in 15mcg instead of 150. I did not realize this until i reached home and received a call from the nurse to verify the dose. The patient basically received a 15 of fentanyl for about 1 hour or so.I am new in the ICU ( less than a year) and this is the first time this has happened. I am not sure what they will do about this but the Rn seemed pretty upset about the situation. How big of an error is this? Also, we always check the drips after giving report, but the RN got busy with the other patient and said she will do later. I have learnt my lesson to be careful and not rush with medications. Any input/ advice will be highly appreciated.
    This is minor, not major, in the grand scale of things.

    However, in my facility, both nurses are at the bedside and verify the IV rates together.

    If you have multiple fluids running, FOLLOW each line FROM each bag to each drip port to make sure that what you THINK is running is actually running. Sometimes bags and tubing gets changed and puts back in the wrong port so you discover later it is at the wrong rate....yup, happened to me...that is how I know to check it now.

    I always, after resetting a pump, take one last conscious look before walking away and say to myself, "Ok, 150 mcg per hour..."

    I got in a hurry once and screwed up huge...never, ever again.
  3. 1
    Quote from Maevish
    Definately agree! Once I thought I'd given too much of a medication for some reason (there wasn't even more than the intended dose in the vial!! haha), and I was sweating bullets until I realized there was no way that could have happened.

    Please PLEASE freak out over this small one and let it be your only one, since no harm came to the patient. It's really scarey when people act like it's no big deal (probably just trying to make you feel better, which is kind) because it COULD have been something much worse. This is a good little wake-up call for you. We've all made an error, small or large, or will and it should freak you out. It's truely scarey when people act like a med error or near miss is no big deal.
    Please don't 'freak out' over anything in the ICU. That's not the place.
    Maevish likes this.
  4. 0
    Quote from Biffbradford
    Please don't 'freak out' over anything in the ICU. That's not the place.

    I didn't mean AT WORK....obviously that's not the time or the place (I should've been clearer). I meant that it's not something to be taken lightly even though it was a minor mistake. I just meant that maybe it should make you sweat a little, make your heart race a little, and make you hyper aware of everything you do after that.

    Even after I almost hung the right drug, right time, right dose, right route one night, it had my other patients' name on it and that freaked me out that I'd gotten busy and let that go, even though everything would've been fine.

    Like the other people said, it's a learning experience, tell yourself your still a good nurse, and that you've learned your lesson and move on from there. I just felt like everyone was making light of a med error and I think it should make you quake a little when something like that happens.
  5. 0
    The nurse that called you at home took responsibility for the patient- that generaly means she checked off the IVs on hand-off. If it was running at the wrong rate for long enough for yo to get home before she called you on it, it is as much her error as yours. It all depends on how anal-retentive you are as to how you view this incident. From your explanation of how this happened it is pretty clear that you were acting in the intrest of the patient and just mis-entered the rate on the pump. I kinda think that is why we have better staffing in critical care and nurses at the bedside. With the number of titrations that happen on a critical patient in a shift the odds of an erroneous entry go up pretty high- you can't get rid of all human error. The important thing is the error is noticed and corrected before harm is done to the patient. Where I work our pumps can be titrated in mcg/kg/min. It is very easy to punch in 15mcg/kg/min on your neo drip instead of .15mcg/kg/min. See a change in your patient you don't understand? Did you touch the pumps recently? That is the first thing I check. Sure, you made an error in settings. That will happen from time to time. The important thing is when it was caught and what was the effect on the patient. In this case- no harm/ no foul. In the future, I would give a bolus or push dose to provide sedation pre-proceedure, and leave the drip rate alone. Don't let this make you nuts. The nurse that called you at home was being a witch and was trying to get your goat. Put your goat away and let it drop. If she brings it up again I would certainly ask her why she didn't check her pumps for so long after she took report. Dosen't she know how to assess a patient??!!
  6. 0
    I do agree that every medication error is a "big deal" in theory because the issue is the the action (or lack there of) and not the consequence. You were lucky since it was just a fentanyl drip and 15mcg/hr is not a problem.. call it a sedation vacation or an agressive titration off , but what if we were talking about levophed/dopamine/cardene.... then it could of been a HUGE problem.

    she should not of called you and scared the bejesus out of you... I would of waited till you came back,.. told you about it nicely and firmly reminded that its very important to do double checks ,.. and the one thing that can't be rushed is medication. If she wasn't so high and mighty she should of also apologized because it is her duty to double check with you.

    Don't let this bring you down, just use this as a learning experience.
  7. 0
    Learn a lesson, take it seriously because it was an error. Realize that NO HARM came to the patient and don't beat yourself up about it. Learn and move on.
  8. 0
    I screwed up one time on a drip and could have KILLED my patient with a pressor and putting in the wrong rate(that was VERY high is all I'll say). It was horrible. I think I shook and was in a state of shock for several days. I was hysterical crying home. It was the end of the shift, I was busy all day and just worn out. Nonstop. I think that's why I made the error, I wasn't thinking clearly and was rushed.

    I think it just shows what a great nurse you are that you're so concerned about this, b/c yes maybe you're patient would have been agitated & possibly self extubate, but really a smaller dose of Fentanly for an hour or two is not the end of the world.

    A lot of hospitals utilize tools where you can report this. Maybe if you do, your management will really enforce the change of shift drip checks and that nurse would have known it's not a possibility to skip the change of shift drip check. I know where I currently work, the change of shift drip check is not done at all (I'm on a travel assignment).


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