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| No. 90 | 
Feb 05, 2007, 09:54 AM
 Re: Patient died from 8GMs of Dilantin
The pyxis, the pharmacist, the doctor, the system. WHATEVER. Whoever is injecting a drug into a patient has the ultimate responsibility to know what they are giving. and what is appropriate. If they don't, it takes 5 minutes to look something up. I have NEVER worked in a place that didn't have some kind of drug reference book. There is a reason that nurses are licensed, educated, trusted. If you are practicing "blind" nursing, then maybe you should get out. If YOU are the one carrying the medication to the patient, then YOU are the one responsible for their safety, I don't care how busy it is. You have a duty as a PROFESSIONAL.
 | | Advertisement Sponsored Links | | | | No. 91 |
Feb 05, 2007, 01:40 PM
Re: Patient died from 8GMs of Dilantin Originally Posted by edsdcs  wow, 32 vials! that should have alerted the nurse alone.
I totally agree. And it took enough time to get all those vials, and she still didn't stop and think. I wonder, did any coworkers witness her preparing the Dilantin?
| | No. 92 |
Feb 05, 2007, 10:21 PM
Updated
Feb 05, 2007 at 10:34 PM by rnin02
Re: Patient died from 8GMs of Dilantin Originally Posted by Hi_r_ed as RN IMy concern though is the pyxis system...Shouldnt it be able to identify when the dosage is incorrect for a particular pt? This is a computerized system.It should be able to block a nurse from getting in excess of the correct dose for a particular pt.
In my mind once the pharmacist profiles the correct dosage, once the maximum is taken out then the nurse shouldnt be able to get any more of the medication. 
We are living in a computerized age and so we should maximise the use of these computer systems to minimize errors of this nature.
I guess it depends on how the pyxis dispenses the medication? Our pyxis opens the main drawer and/or container and if you want to, you can take out all the meds in the container once it is open. And you can go back for a second dose, if the pyxis inventory shows that there is still medication in there. Do other pyxis' only allow one dose at a time to be retrieved physically?
| | No. 93 |
Feb 06, 2007, 07:25 AM
 Re: Patient died from 8GMs of Dilantin Originally Posted by rnin02 I guess it depends on how the pyxis dispenses the medication? Our pyxis opens the main drawer and/or container and if you want to, you can take out all the meds in the container once it is open. And you can go back for a second dose, if the pyxis inventory shows that there is still medication in there. Do other pyxis' only allow one dose at a time to be retrieved physically?
That seem to be how all the pyxis systems work.I was just saying it would be good to implement some safeguard to prevent overdosing a patient in the future.Since its a computer it shouldnt be difficult for some computer wiz to come up with a system that would prevent another drawer from opening for that particular med.
That way this nurse wouldnt have been able to get 32 bottles (remember she had to go to different pyxis machines).
| | No. 94 |
Feb 06, 2007, 08:41 PM
Updated
Feb 06, 2007 at 09:13 PM by ekl
 Re: Patient died from 8GMs of Dilantin
The patient must to have been comatose to tolerate the infusion. Dilantin infusions are painful.  | | No. 95 |
Feb 06, 2007, 08:54 PM
Re: Patient died from 8GMs of Dilantin
I feel terribly for the pt, family and nurse. This is a lesson to all nurses to stop being affraid to "Look Dumb" (better than being so). I always ask my fellow nurses about things, and I've been a nurse for more than 14 years. I question doctors too, and I talk to the pharmacy a lot. We see a lot of strange doses where I work, but clarification never goes out of style. I've even asked the pt what their normal dose of said medication is, sometimes they know, sometimes they don't.
Nurses should not be affraid to ask questions; which means nurses should not put each other down and make one another feel stupid therefore so they can freely ask such "Stupid" questions.
| | No. 96 |
Feb 06, 2007, 09:15 PM
Re: Patient died from 8GMs of Dilantin Originally Posted by staceylee67 I feel terribly for the pt, family and nurse. This is a lesson to all nurses to stop being affraid to "Look Dumb" (better than being so). I always ask my fellow nurses about things, and I've been a nurse for more than 14 years. I question doctors too, and I talk to the pharmacy a lot. We see a lot of strange doses where I work, but clarification never goes out of style. I've even asked the pt what their normal dose of said medication is, sometimes they know, sometimes they don't.
Nurses should not be affraid to ask questions; which means nurses should not put each other down and make one another feel stupid therefore so they can freely ask such "Stupid" questions.
So true, doctors consult with each other all the time, but when a nurse tries to consult with another nurse, you get that put-down, made to feel stupid reaction.
| | No. 97 |
Feb 07, 2007, 04:39 AM
Re: Patient died from 8GMs of Dilantin
she should have had her super ego ring the bell with the dose. maybe she was pre-occupied or she thouht she was that competent enough to make the act. it just sad that just by one mistake her career is flushed down the toiliet.
this kind of incident should really be read by other nurses to prevent such mistake.
| | No. 98 |
Feb 07, 2007, 08:36 AM
Updated
Feb 07, 2007 at 09:00 AM by Boston Blackie
Re: Patient died from 8GMs of Dilantin
What happened to her knowledge learned in Materia Medica & most of all what happened to checking Doctor's order & checking before drawing, then before giving. What is happening to the Nursing Profession- it's very scary. As a patient, I still check what they are administering. Just unbelievable! Boston Blackie-Graduate of Diploma School of Nursing,1955.
| | No. 99 |
Feb 07, 2007, 08:54 AM
Re: Patient died from 8GMs of Dilantin Originally Posted by Boston Blackie What happened to her knowledge learned in Materia Medica & most of all what happened to checking Doctor's order & checking before drawing, then before giving. What is happening to the Nursing Profession- it's very scary. As a patient, I still check what they are administering. Someone dropped the ball allowing this Nurse to Practice. Boston Blackie-Graduate of Diploma School of Nursing,1955.
I don't think you can extrapolate what is happening to the nursing profession from the mistaken actions (serious as they are) of one person. Instead, look at the almost universal reresponses on this thread that reinforce the correct approach to giving meds. That ought to provide some reassurance that nursing is alive and well and being practiced with great care by the majority.
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