Please, please, please remember the 5 rights!

  1. 16 We recently had a HUGE med error in our facility which I think can serve as a good reminder to all of us to NEVER get complacent, NEVER trust anyone else to handle our medications and ALWAYS check the 5 rights before we give a medication.

    We are fortunate in my pediatric hospital to have a satellite pharmacy for our medications. So if we need a stat med, pharmacy can make it right on the floor. We don't have to wait for it to be sent up from the regular pharmacy. This pharmacy covers PICU, NICU and Peds.

    Recently a nurse from the Peds floor came to pick up a STAT dose of IV anti-epileptic medication for a patient having frequent seizures. The pharmacist handed her the medication, she went back to the floor, and gave the medication.

    Immediately after she began giving the medication, the patient began gasping for breath and then stopped breathing. A code was called and our PICU team rushed over. The child was intubated and brought to our unit. It was suspected that he was seizing. He never lost a pulse, but was not breathing. We started out standard work up for a patient who had coded- ABG, glucose, blood culture, CBC, hook up to ventilator, call for x-ray and call for CT. EEG was set up which showed the patient was not seizing- but he was still not waking up.

    After maybe 20 minutes someone from the peds floor came over hand handed the medication syringe to our attending physician. She simply said, "This is what he got." It was a syringe filled with Vecuronium. (For those who aren't familiar with Vec, it's a paralytic used for patients who are intubated. It paralyses all muscles- including the muscles used for respirations. But it has no sedative effects and leaves you totally awake and aware underneath.) This child had gotten the full dose (clearly labeled with the name of one of our PICU patients) that was meant to run over a 24 hour period, in about 15 minutes. He wasn't seizing- he was fighting to breathe. He wasn't waking up because he couldn't wake up. But he still felt all that was happening to him during the code.

    If the 5 rights had been followed in this situation, everything would have been prevented. It was the wrong patient, the wrong medication, the wrong dose, the wrong time, the wrong reason. We, as nurses, were completely floored by the occurrence, and I think we all ran to our patient's rooms to double check everything that we had hanging.

    So please, everyone. Even if it's an emergency med. Even if you're really busy. Even if the pharmacist handed you the syringe and said "this is what you need. Always check your medications before you give them.


    Very fortunately, the patient suffered no long-term consequences as a result of this experience. He was extubated once the medication wore off. His CT showed no damage. The next day he was up and running around the ICU like nothing had ever happened. He is a very lucky boy.
  2. Visit  Ashley, PICU RN profile page

    About Ashley, PICU RN

    From 'New Jersey'; Joined Apr '11; Posts: 2,561; Likes: 4,431.

    44 Comments so far...

  3. Visit  Esme12 profile page
    7
    HOLY CRAP!!!!!! What a nightmare. Thank God the little guy's ok. See that's why nurses are such spelling accuracy freaks and obsessive to detail.
  4. Visit  sapphire18 profile page
    1
    Oh my goodness- that is one of the scariest things I have ever heard. Just curious, do you know what's going to happen to the nurse?
    herring_RN likes this.
  5. Visit  buytheshoes11 profile page
    1
    How terrifying! I am glad that the little guy is okay though!

    It's like what the OP said though, even in an emergency it's so important to remember the five rights before you pass the med!
    herring_RN likes this.
  6. Visit  MyMystudentRN profile page
    1
    omg how horrible!! thank God the kid is okay....wow when i was a manager i made sure my staff were WELL trained on passing medications because i did not want ANYTHING like this to ever happen with one of our kids
    herring_RN likes this.
  7. Visit  Mulan profile page
    2
    Quote from Esme12
    HOLY CRAP!!!!!! See that's why nurses are such spelling accuracy freaks and obsessive to detail.
    I guess not all nurses.
    nursel56 and whichone'spink like this.
  8. Visit  libran1984 profile page
    0
    I'm gonna have nightmares now... Geez.
  9. Visit  kids profile page
    0
    I literally gasped when I read the op.
    So many things wrong in one spot, thank heavens for a positive outcome.
  10. Visit  RNsRWe profile page
    2
    I would rather have had a Thank You For This Post button, but as there was none, I hit "Like".

    Holy crap doesn't begin to cover it. Any idea of the disciplinary action for the negligent nurse? Yes, negligent....had she checked anything at all before pushing that med, this entire debacle would have been prevented. She created a crisis where none existed, because she did nothing to prevent it.

    Thank goodness someone thought to check the trash (sharps bin??) for the used syringe, so that the med trail could be followed before this poor kid was tested any further for his "mystery illness".
    Aurora77 and herring_RN like this.
  11. Visit  deftonez188 profile page
    2
    Mouth agape.
    Scarlette Wings and herring_RN like this.
  12. Visit  rubato profile page
    0
    S**t! How terrifying for the poor little guy. I'm glad he's okay. I hope to hear what's happening to the nurse.
  13. Visit  wooh profile page
    8
    Quote from rubato
    I hope to hear what's happening to the nurse.
    And the pharmacist. Two people screwed up here. Just because the nurses is the last person in the chain, doesn't mean the nurse was the ONLY PERSON that could have stopped this. A pharmacist that will hand over a paralytic to just anyone isn't anymore without guilt than the nurse that didn't check the syringe.
    TopazLover, JZ_RN, anotherone, and 5 others like this.
  14. Visit  rubato profile page
    1
    Quote from wooh
    And the pharmacist. Two people screwed up here. Just because the nurses is the last person in the chain, doesn't mean the nurse was the ONLY PERSON that could have stopped this. A pharmacist that will hand over a paralytic to just anyone isn't anymore without guilt than the nurse that didn't check the syringe.
    Absolutely. Didn't mean to blame only the nurse.
    JZ_RN likes this.

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