Another tragic med error - page 3

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  1. by   marikat534
    After reading that my stomach dropped. It makes you stop and realize that one can never be too careful to prevent a tragedy.
  2. by   Mulan
    Quote from Jolie
    Besides being chock full of systems errors from the supplier to the pharmacy to the nurse to the physician, this situation points out the critical importance of having experienced staff to care for patients and administer medications. I'll bet that the nurse who gave this med had never done so before (which certainly doesn't excuse her error or relieve her of the responsibility to look it up), but an experienced nurse would have recognized the correct dose.

    As an aside, and please don't flame me-I am not blaming the parents! This siutuation points out the completely unexpected and unanticipated risks of any elective healthcare treatment. Americans have gotten so used to perfect outcomes that they fail to understand that every medication, test and treatment has potentially fatal risks, no matter how miniscule.
    I wonder how short the child actually was.

    Better short than dead.
  3. by   Grace Oz
    How terribly sad. my heart goes out to all concerned. It's not as though it was a deliberate act. It was a terrible tragic mistake.
    All the more tragic since this was not for a life saving procedure.
    Sometimes it's just best to accept our flaws & decifits and leave well alone.
    Bless his little soul and may his parents find comfort somehow.
  4. by   kstec
    I looked this drug up on the internet and it looks as though the pharmacy sent up 2 bottles of 300ml bottles containing 30 grams of arginine each. Even if the pharmacist read the order as 57.5 grams instead of 5.75gram, wouldn't you think he'd double check when two bottles showed up after ordering them? I'm not trying to place blame but it just seems that with such a large quantity of anything especially on a child that it would be questioned somewhere along the way. I remember working in a hospital pharmacy and an order had been entered by the pharmacist for a pediatric TPN and somehow it got entered and almost pumped on the TPN/PPN compounder before I realized that our KCL kept running out, then I looked and low and behold the kid was going to get 300meq of KCL in a liter bag. Can we say instant death. I stopped the machine and screamed "What the he!!" At the time I was in LPN school and that scared the holy crap out of me. I feel bad for all involved but somehow the checks and balances didn't work. If I hadn't known the normal amount of KCL for peds patients I would of never thought twice about refilling the KCL each time the bottle ran out. Someone was watching over that little person that day. Sorry so long, but this reminding me of my scare in pharmacy.

    r-gene (Arginine Hydrochloride) injection, solution
    [Fresenius Kabi Clayton, L.P.]



    DESCRIPTION

    Each 100 mL of R-Gene 10 (10% Arginine Hydrochloride Injection, USP) for intravenous use contains 10 g of L-Arginine Hydrochloride, USP in Water for Injection, USP. L-arginine is a naturally occurring amino acid.
    R-Gene 10 is hypertonic (950 mOsmol/liter) and contains 47.5 mEq of chloride ion per 100 mL of solution. The pH is adjusted to 5.6 (5.0-6.5) with arginine base or hydrochloric acid.
  5. by   elizabells
    Quote from RainDreamer
    Is it not the norm to check neonatal/pediatric doses with another nurse?
    Not everywhere, Rain. I check everything against our protocols, and any vasoactive drips with a second RN, but the only thing on our unit that we are *required* to 2 RN check is blood. I do double-checks because I'm skittish, not because it's policy.
  6. by   RainDreamer
    Quote from elizabells
    Not everywhere, Rain. I check everything against our protocols, and any vasoactive drips with a second RN, but the only thing on our unit that we are *required* to 2 RN check is blood. I do double-checks because I'm skittish, not because it's policy.
    Oh wow. We have to check any kind of medication, drips, fluids, etc. with another RN. Even glycerin chips lol.
  7. by   elizabells
    Quote from RainDreamer
    Oh wow. We have to check any kind of medication, drips, fluids, etc. with another RN. Even glycerin chips lol.
    Oh, wait, I told a lie. We have to check IVF at shift handoff, and sign off on the TPN order sheet. But that's it. I guess there's a built-in check for narcs at the Pyxis with witnessing, but people don't always do anything more than type in their code for you and run.
  8. by   RainDreamer
    Quote from elizabells
    Oh, wait, I told a lie. We have to check IVF at shift handoff, and sign off on the TPN order sheet. But that's it. I guess there's a built-in check for narcs at the Pyxis with witnessing, but people don't always do anything more than type in their code for you and run.
    We do that at the Pyxis too lol. I know that's bad, but we have to check off with another RN anyway, so they end up witnessing our waste after we draw it up.

    It does get tedious after a while having to check everything, stuff like fer-in-sol and other things that you know are correct. Especially if you have a kid on a ton of meds.

    But for the major stuff, I'm like you in that I'm skittish and I always have to double check everything anyway.
  9. by   Sabby_NC
    Quote from earle58
    how did this get by all involved?
    that's the scariest part.
    so, so sad and needless.

    leslie

    Very GOOD point Leslie...
  10. by   cmo421
    Someone was way too far into their comfort zone. Sad. I am sure that those involved will spend many sleepless nights. Hindsight is always 20/20 and sadly enough, it is only when major mistakes are made, that policies r reviewed and tightened,thus saving many other lives! My heart and sympathy goes out to his family and all those involved.
    Interesting to note that the family has already settled with the facility. I bet they just want to move on rather then have a media circus.
  11. by   pepperann35
    Quote from cardiacRN2006
    I would think the opposite. I would think that familiar drugs are easier to make mistakes on, because we assume a lot about them, whereas on new drugs we are more likely to review info on it.

    I always look up any new drug.
    I would think that working with pediatrics means that a lot of the nurses look up doses based on weight.

    Seems like a lot of errors happened at once. How sad...
    Wow! I am sorry to say this, but that was really dumb! Whoever mixed that IV had the proper dose prescription.Why in the world did this happen? The boys MOM asked if it was the correct dose, not the nurse, according to the article. Wow, how sad!
  12. by   cmo421
    Quote from pepperann35
    Wow! I am sorry to say this, but that was really dumb! Whoever mixed that IV had the proper dose prescription.Why in the world did this happen? The boys MOM asked if it was the correct dose, not the nurse, according to the article. Wow, how sad!


    Very sad and preventable error. But ,people make mistakes especially when too comfortable. I would not want to be that nurse today.
    I feel very lucky that I have not made a grave error. Stories like this one should make us all more careful in our practice and take us out of our comfort zone.
  13. by   TrudyRN
    I think the pharmacist's role has been downplayed. I'm not at all sure the nurse is responsible for this fatal error. It sounds like Pharmacy are the ones who screwed up.

    And I can't help but wonder about the atmosphere where this occurred. Was it too rushed? Short-staffed? If the test is so routine, why were the pharmacist and nurse so unfamiliar with it?

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