Avoiding inadvertent IV injection of oral liquids - page 3
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Dec 18, '12 by psu_213Quote from FlyingScotIn fact, the first line of the news letter article says "purposely administered."I wouldn't call what she did "inadvertent". - Dec 18, '12 by psu_213Quote from turnforthenurseRNI was thinking of that one too. That was truly (or so it appeared) inadvertent. What happened here was done on purpose. I don't know enough to say that she was trying to harm the pt. For right now, I'm going to stick with supremely ignorant.
I still do not understand how a nurse can inadvertently inject oral meds as IV. That reminds me of that nurse or student or whoever it was who injected a patient with COFFEE...nrsang97 likes this. - Dec 18, '12 by psu_213Another example from my hospital--
A resident ordered a particular med that was a powder applied to the skin (don't ask, I don't know the exact med). Our pharmacy does not usually even carry normally carry it, but for some reason they had a small supply of it. Sent the med up with a sticker on it "for topical use only." Well, apparently the resident had ordered it "IV." The pharmacy should have seen this part of the order, but, as I understand it, they contacted neither the resident nor the nurse. The nurse got the powder and then called the resident about the "IV" part of the order. The resident said that, yes, it is to be given IV. The nurse reconstituted it and gave it IV. Resulted in the death of the patient.
When you read these things you ask "how could anyone be so stupid?" I don't know the answer to that, all I can say is that these ridiculous sounding errors occur.NRSKarenRN likes this. - Dec 18, '12 by MN-NurseQuote from psu_213Every time I see something like this, I am reminded about how much I love our pharmacists. Even the very rare arrogant jerk pharmacist.The pharmacy should have seen this part of the order, but, as I understand it, they contacted neither the resident nor the nurse.
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Dec 19, '12 by nrsang97Quote from NeuroICU_SaraIF our patients have an OG/NG/PEG they now have the nimodipine come up in those amber colored oral syringes. We never had an incident like that happen in our ICU, but after hearing about them in other hospitals our pharmacy changed the way it dispensed nimodipine for our tube feed patients.I am a neuro ICU nurse and many of my patients are prescribed Nimodopine for vasospasm. These are large,coated pills that can not be crushed. Many nurses poke holes in them with needles and either squirt the liquid into a med cup or aspirate into a 5-10mL syringe.
This enables you to mix with other meds and administer them via a DHT, NGT/OGT, or PEG.
One night a new graduate aspirated the medication into a syringe. She took the needle off and went over to the patient and injected it into a PIV. The patient almost died. And the new grads preceptor was right there watching her aspirate the medication with the syringe.
Nurses need to be serious about safety at all times. The only hard stop to prevent this type of medication error (wrong route) would be to only have liquid form available in patient's that can not swallow their medications.wooh likes this.