Wanna hear this major drug booboo?

  1. 2 unvented kids had their heplocks flushed with vecuronium.
    Guess what happened?

    Our drug fridge storage for vec, heplock flush and insulin were dangerous and everyone knew it. Too close to each other. 10:1 flush resembled our vec bottles and insulin resembled 1:1 flush bottles. (of course WE CAN ALL READ RIGHT?) Our drugs are finally labelled completely different now. I don't know who it was but it was someone experienced. And the same nurse for both kids. I feel so bad for her. How awful for her. The 2 babies were fine after a while vented.
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  2. 7 Comments

  3. by   dawngloves
    Wow! We only have Pavulon in a locked fridge with Surfactant and something else, I can't think of what....
    That poor nurse! Those poor kids! I'd quit if I did that for sure!
  4. by   NicuGal
    Oh man, that sucks and it sucks big time! We don't keep Vec on the unit and we have one vial of Pavulon that is locked up. I would have thrown up if I did that. That poor girl!

    A good reminder to check, recheck and check again any vial you pick up!
  5. by   KRVRN
    We USED to have vec right in our Pyxis. We reconstituted t ourselves and left it the fridge. Now we have to get it from pharmacy. But I don't know what that solves... Pharmacy sends us a vial, we reconstitute it and then we put it where? Our fridge of course. Vec is a double check med, but the problem is is that heparin flush obviously isn't. And that's where the problem is. Basically we need two fridges: one for non-checked meds like flush and antibiotics. And one for double checked meds like insulin and vec. We have one med fridge and our sucrose is even floating around in there too! Of course that is in an oral med bottle that's different but that's not the point. There's some changes that need to take place. Imagine if a heplock had been flushed with insulin! THAT would be quite an overdose. It would probably take a few minutes to take effect and would we immediately know what the problem was when it did?

    Ahhhh, and JHACO comes next month...
  6. by   NicuGal
    We don't stock hep flush on the floor. We only use hep flushes on central lines and piccs that are capped. We use NS flushes for our IIP's. The only time we use Hep flush on a peripheral IV is if the kid is a terrible stick.

    Our hep flushes come up in a bag from pharmacy and each child gets his or her own. No sharing, no mixing.
  7. by   renerian
    YIKES.................

    renerian
  8. by   karenelizabeth
    God how scary

    We have to have all drugs checked and sighned by 2 nurses can be time-consuming but cuts out most (by no means all) mistakes.

    Out hep flush is also kept in a different fridge.
  9. by   guest01
    Wow, poor gal. Our hep lock flush is in a vial in a chest of drawers with other meds. I'm new so I've never had to use Vec: to tell you the truth, I don't even know where it is. And we flush all our heplocks q 8. We add heparin to our fluids like D10.

    I hope I never make a mistake like that.

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