IV drip dose error

  1. 0
    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.
  2. 27 Comments so far...

  3. 10
    So the pt. received 15 mcg/hr Fentanyl instead of 100 mcg/hr? For an hour or two? Mistakes happen; no big deal....Could have been worse. Your RN colleague needs to chill out and not be so upset about petty stuff. I wouldn't have bothered to call you, I would have just given you a polite reminder the next time I ran into you.
  4. 9
    Agreed. Too little pain med? Small potatoes. I was sending a patient to OR and turned the Heparin drip off at the prescribed time (6 hrs prior? I forget). An hour before OR, I cleared the pumps (I/O) but when I did that, I had to turn that Heparin pump back on briefly, and somehow _started it_ again. Anaesthesia rounded some 15 mins later and saw it running and freaked out. "No No" it's been off for hours I insisted! Stat. PTT was well within the limits they needed and pt went to OR on schedule. Lesson: Disconnect the line if you turn a drip off permanently and always do a quick 'idiot check' before moving on.
    imaginations, MLMRN1120, opossum, and 6 others like this.
  5. 0
    I have to agree too little of Fentanyl is not such a big deal. The worst thing would have been the patient started to stir and started fighting the vent. It's not like you you changed it to 1500mcg an hour, and even then the patient is already tubed.
  6. 12
    You should have told the RN that you were saving the other 135mcg for him or her to calm down with and furthermore don't ever call you at home for something that #1. can be found on the chart/orders....and #2 is a bs call!

    honest mistake..no harm done....now is the time for you to call the RN when they didn't document the smell of the urine!!!
    nursenick20, divaRN*, MLMRN1120, and 9 others like this.
  7. 0
    Oh, so the other nurse is perfect? 15mcg is no big deal for an hour. No harm done to the patient.
  8. 5
    I don't agree that it's "no big deal" as every medication error is a big deal in my opinion. But - the patient wasn't harmed, so count it as a learning experience. You should learn something from the situation so that this particular mistake doesn't happen again. That's how we learn and gain experience. People make mistakes.
    Maevish, cwhitebn, chare, and 2 others like this.
  9. 1
    Quote from ghillbert
    I don't agree that it's "no big deal" as every medication error is a big deal in my opinion. But - the patient wasn't harmed, so count it as a learning experience. You should learn something from the situation so that this particular mistake doesn't happen again. That's how we learn and gain experience. People make mistakes.
    I agree, ALL medication error is a big deal! Just be careful next time and learn from your mistakes.
    Nccity2002 likes this.
  10. 1
    Next time, just bolus the pt w/50mcg for the turn.

    If the pt had woken up and extubated himself-then you bet it would have been a big deal.

    We all make mistakes and hopefully learn from them...
    divaRN* likes this.
  11. 0
    [quote=CCL RN;4769118]Next time, just bolus the pt w/50mcg for the turn.

    If the pt had woken up and extubated himself-then you bet it would have been a big deal.

    We all make mistakes and hopefully learn from them...[/quo


    Ditto. It is not as benign as it seems.


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