Patient died from 8GMs of Dilantin

misty_maurie · Feb 07, 2007, 12:09 PM

Re: Patient died from 8GMs of Dilantin

Originally Posted by fultzymom

I meant the 8000mg the nurse gave. What I meant was I can not believe that she did not question giving 8000mg of Dilantin. I could not imagine not questioning an order for 8000 mg of anything.

I totally agree! 8000mg of anything is soooo much... I am sure this nurse is looking back at this and saying to herself, "what was I thinking??!!" Everyone is entitled to make mistakes but when it costs someone their lives that is devestating. I feel for this nurse too. What a horrible thing to have to live with for the rest of her life! I guess this story really drives home the need to know the meds you are giving and that it is crucial to get clarification if something doesnt seem right. SAD!

LuvsdolphinsRN · Feb 07, 2007, 06:59 PM

Re: Patient died from 8GMs of Dilantin

I am very sad for the family and the nurse involved. She will never be the same again either. Once the life is gone it never comes back. I'm sure if she could do it all over again she would do it differently. I pray this is a lesson for all licensed nurses to recheck the amt of dispensed meds!!!

*SKM-NURSIEPOOH* · Feb 07, 2007, 07:33 PM

Re: Patient died from 8GMs of Dilantin

Originally Posted by prmenrs

I wonder if the doc used the "trailing zero"? Instead of writing 800mg, he wrote 800.0mg? Which is one of the no-no's from JACHO to prevent errors like this one.

Still doesn't explain all the other breaks in the process, but could explain how it started...

Or perhaps the doc wrote 8000 mcg & the *c* in mcg wasn't legible?

My God though....32 vials? I would've called the doc back to verify the order & while awaiting his call...I would've placed a call to pharmacy to triple check the concentration of an IV gtt (considering she meant to administer the dilantin as an IV gtt),

There are a lot of holes in the story that we'll never hear...but I'm speculating that the patient must've been given Ativan IV push or something & her seizures subsided enough for this nsg to go all around the facility to retrieve the vials.

I can also see this as being a system error in that no pyxis machine should've dispensed more than three vials of certain medications @ a time for just such a situation. If there had been such a safety net...this tragedy would've been caught.

At any rate...I feel extremely badly for all parties involved. May God be with them all.

Moe

*SKM-NURSIEPOOH* · Feb 07, 2007, 08:03 PM

Re: Patient died from 8GMs of Dilantin

Originally Posted by Hi_r_ed as RN

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).

Why don't they set-up the pyxis in such a way that we would have to count the initial inventory & take the amount we want out, much like how we would do when retrieving narcotics from the pyxis system. When retrieving narcotics, we have to count what's in the drawer, take out the amount of narcs we're taking, then close the drawer. The drawer won't close without at least one med being entered as being retrieved unless you press cancel. An discrepancy will occur if one takes narcs & not document it in the pyxis...the very next person will generate the discrepancy when they do the initial count. The pyxis will then generate a report which will show the last person who opened the drawer prior & it would be down to the charge nsg, the previous nsg, & the current nsg to clear-up the discrepancy.

At any rate, the pyxis system should be revamp to prevent this sort of error.

Moe

mellendis · Feb 08, 2007, 12:09 AM

Re: Patient died from 8GMs of Dilantin

common sense isn'y so common after all

Boston Blackie · Feb 08, 2007, 08:42 AM

Re: Patient died from 8GMs of Dilantin

Having been a Registered Nurse for many years, I have the utmost respect for the Nursing Profession. In my response I was not critizing the Nursing Profession-May God Bless & watch over all of them-my concern is with our system that continually changes, taking away the resources e.g. - enough Nurses & staff to give the proper amount of time to carry out their work. The pressure is driving Nurses from their beloved Profession. We probably will never know why that Nurse missed all the Red flags & her reasoning was absent- overwhelmed?? Burned out??? The A.N.A., as hard as they work to solve the problems, can only do so much. The fight is not over yet!
"Have a Heart that never hardens, a Temper that never tires & a Touch that never hurts" Addison

psychRN33 · Feb 08, 2007, 06:27 PM

Re: Patient died from 8GMs of Dilantin

Clearly the nurse could be charged with malpractice. She was unable to perform at a level comenerate with an RN. This experience clearly points out the necessity for nurses to be familiar with the typical doses for the meds that they dispense. If not, they need to to find the information before dispensing the drug. One of the easiest and most accessible ways to get this information is to do a Internet search on the drug name.

ERERER · Feb 08, 2007, 06:37 PM

Re: Patient died from 8GMs of Dilantin

"At any rate, the pyxis system should be revamp to prevent this sort of error. "
I STILL think that the main point here is being missed. I don't give a damn what kind of med access system you have. If you are injecting a drug into a human being YOU are responsible for knowing the usual dose, indication, and side effects of that drug./ Whatever happened to personal responsibility? This whining about a computer system protecting us from errors makes me nauseous. Nursing is a PROFESSION, we are not waitresses. Outside of a code, which your ACLS should have prepared you for, You always have time to take 3 minutes to look up a drug you are unfamiliar with. Most of the drug errors committed are from laziness. I'm sorry to say, I'm fed up with the direction that nursing has taken this century, blaming someone else for your errors. That nurse should be in jail.

jwl300 · Feb 08, 2007, 08:06 PM

Re: Patient died from 8GMs of Dilantin

My thoughts are summed up with:

language barrier

If the nurse is from Jamaica, maybe she didn't hear the doctor correctly if it was verbal. Dialects can make understanding a challenge. Which is where was the concept of time out and reading back what the doctor said? Maybe he told her: xxxx mg's as he was writing and she never viewed the written order? No, it doesn't make it right, but how many times have orders been taken without a proper readback?

moonrose2u · Feb 10, 2007, 09:36 AM

Re: Patient died from 8GMs of Dilantin

ok. i am curious...what hospital did this occur in? i couldn't find the news story on the internet...

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Patient died from 8GMs of Dilantin

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