Girl dies after medication error - pg.3 | allnurses

Girl dies after medication error - page 4

Alicia Coleman was born relatively healthy, her mother said, even though she was three months' premature and weighed little more than 2 pounds at birth. Things grew worse when Alicia came down... Read More

  1. Visit  carolinapooh profile page
    3
    I hate to say this, but given some of the stuff I've been told by RNs in transfer reports, such an error would not surprise me (and I can give a LOT for human error).

    I got report one night from a medical floor - a cancer patient of ours was being transferred down to our unit since we'd just had a bed become available. The patient had a right chest wall port. The RN told me, "Well, we accessed his port but we're waiting for a chest xray to make sure it's OK to use."

    Alarms went off in my head.

    I happened to have the patient's med record open on the computer in front of me, and as I flipped through it I asked the RN if the port was new (I thought I recognized the patient and if I was right, the port WASN'T new). She said no, but they had to wait to check for placement.

    I then asked her what kind of needle they used to access the port, and was relieved to hear they'd actually used a Huber (I heard about a patient that the staff had tried to access the port with a STANDARD 18 gauge - no, no, no - they ended up severing the port tubing with all the jabbing and a five inch long piece ended up in the patient's PULMONARY ARTERY!!). I told her that you don't order a CXR for an old port because the ports are placed by interventional radiology and the placement is confirmed at insertion. The only thing you ordered a CXR for (at this particular place) was a PICC line. And anyway, whenever a port is placed ANYWHERE placement's checked at insertion, whether IR put the thing in or not. Once it's in, it's in, and they recheck it if it's a problem or if it's potentially flipped or whatever.

    This is the answer I got. "Oh, yeah, well, we figured you guys would know more about it anyway." (Then why, pray tell, did you touch it in the first place??)

    My point is, if you don't know what you're dealing with (and there's no shame in it), ask before you use it.
  2. Visit  labrador4122 profile page
    0
    Quote from *babynurse4ever
    the med they improperly routed was questran! i know the childs mother. i can not imagine what she is going through. i dont understand how a "mistake" like that can be made. per mom they even had to mix the med with tap water!!!! i'm sorry even a new grad should know you do not inject anything that is mixed with tap water into a central line. childrens home health care world does not have the same med administration rules as the hospital. they way they administer meds is no different than any typical daycare with the exception of they have nurses administering them. the parents drop off medications and they get put into a basket in the nurses office with the childs name on them. i quite taking my foster child there along time ago when they over hydrated her with her replacement fluids she was getting in her central line. the over hydration cause my foster child to get admitted to the hospital her k+ was 2. i guess i was luckey because i was one that called every hour or two to ask how she was doing and what the iv pumps were set at. if i hadn't she would have been worse off.
    i am angry and sad. something there needs to change!!!!
    very true!
  3. Visit  imintrouble profile page
    9
    I have never seen a nurse deliberately make a med error. I have never seen a nurse not berate themselves when they do commit a med error. I've seen some nurses grieve for days, when something they've done harms a pt. I can only assume those of you throwing big fat stones must have NEVER made a med error. Either that, or you're not a nurse. Making an error humbles you. Reminds you that you're not perfect, and never will be.

    I am not angry at the nurse who is responsible for the little girls' death. She is already living a hell I cannot imagine. To those of you who are feeling superior and infallible, you're not.

    I am saddened by the child's death. My thoughts are with her mother, as I am a mother myself. I have compassion for the nurse, as I am a nurse too.
  4. Visit  Indy profile page
    0
    Questran is such a difficult drug to deal with, I hate it. I hold my breath when opening it because that orange powder just flies right up my nose if I don't, and as an asthmatic I don't appreciate extra crap in my lungs. Then it takes sometimes up to 300 cc warmish tap water to get it to mix just so it will go through a cath tip 60cc syringe without too much resistance. It regularly clogs up peg tubes. This is the adult dose packet of course.

    My point being, I don't see it as a med that would go through a luer lock easily. For one thing I have to give it in 60cc syringes and the very size alone of that huge thing would let someone know, it's not IV even if it were a 60cc luer lock tip instead of a cath tip. I guess it's possible to try to suck it up in a 10cc luer lock but it would take a lot of doing. And it just sounds like it must have been a lot of work to get it IN the child's central line in the first place.

    If the child had an NG tube I can see the possibility also, of the NG being taped around near the ear and the IJ port being near the NG port. Still the problem of the syringe comes into play; the syringe should have been a big ole cath tip thing that wouldn't even fit the port of a central line. I wonder if the facility had the variety of syringe types and such that they should have, or if the nurse was just using whatever was available. I do know I've worked with people who didn't play with a full deck and could do some really dumb things, so in the end we all just have to try to be smarter and hope it's not ourselves that makes such a mistake.
  5. Visit  wooh profile page
    3
    I know at my facility we have NJ tubes that you have to use a luer lock with an adapter to administer meds through them. You can't use the oral syringes on them. I can see where you get the meds ready, have some to give IV, some to give via the J tube, it could be quite easy to grab the wrong one if you get distracted.
    And I have to agree with those saying that nobody is perfect. If you're throwing stones here, you either haven't made a med error YET, or you don't realize that you already have.
  6. Visit  pjpj profile page
    0
    This is so sad
  7. Visit  jl_nurse profile page
    1
    Quote from carolinapooh
    I hate to say this, but given some of the stuff I've been told by RNs in transfer reports, such an error would not surprise me (and I can give a LOT for human error).

    I got report one night from a medical floor - a cancer patient of ours was being transferred down to our unit since we'd just had a bed become available. The patient had a right chest wall port. The RN told me, "Well, we accessed his port but we're waiting for a chest xray to make sure it's OK to use."

    Alarms went off in my head.

    I happened to have the patient's med record open on the computer in front of me, and as I flipped through it I asked the RN if the port was new (I thought I recognized the patient and if I was right, the port WASN'T new). She said no, but they had to wait to check for placement.

    I then asked her what kind of needle they used to access the port, and was relieved to hear they'd actually used a Huber (I heard about a patient that the staff had tried to access the port with a STANDARD 18 gauge - no, no, no - they ended up severing the port tubing with all the jabbing and a five inch long piece ended up in the patient's PULMONARY ARTERY!!). I told her that you don't order a CXR for an old port because the ports are placed by interventional radiology and the placement is confirmed at insertion. The only thing you ordered a CXR for (at this particular place) was a PICC line. And anyway, whenever a port is placed ANYWHERE placement's checked at insertion, whether IR put the thing in or not. Once it's in, it's in, and they recheck it if it's a problem or if it's potentially flipped or whatever.

    This is the answer I got. "Oh, yeah, well, we figured you guys would know more about it anyway." (Then why, pray tell, did you touch it in the first place??)

    My point is, if you don't know what you're dealing with (and there's no shame in it), ask before you use it.

    The last sentence sums everything up! A scary nurse to me is one who never asks questions and assumes to know it all and then cause harm to others. A good nurse, to me, is the nurse that continues to ask questions every day. The day I know it all is the day I want someone to show me the door and kick me out of the hospital.
    labrador4122 likes this.
  8. Visit  labrador4122 profile page
    0
    Quote from imintrouble
    I have never seen a nurse deliberately make a med error. I have never seen a nurse not berate themselves when they do commit a med error. I've seen some nurses grieve for days, when something they've done harms a pt. I can only assume those of you throwing big fat stones must have NEVER made a med error. Either that, or you're not a nurse. Making an error humbles you. Reminds you that you're not perfect, and never will be.

    I am not angry at the nurse who is responsible for the little girls' death. She is already living a hell I cannot imagine. To those of you who are feeling superior and infallible, you're not.

    I am saddened by the child's death. My thoughts are with her mother, as I am a mother myself. I have compassion for the nurse, as I am a nurse too.
    I totally agree with you!
    Once when I missed a medication, my manager told me like I was an idiot "remember the 5 rights"......... and I just remember feeling very embarrased at the way he talked to me.
    I am not saying that I do not make mistakes now, but I have and yes, just like you said, I feel terrible afterwards just like anyone else would.
    I really am super careful when giving IV and PO meds, and check my ID bands before administering.
    but I agreed with what another post said-- if you mix something with tap water do not put it in a central line-- any prudent nurse should know that.


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