Patient died from 8GMs of Dilantin

the first message in this thread has a link to the news story, I believe it was Broward General in Fort Lauderdale

Incredulous. If nurses can't be trusted to consult a medication book or ask a peer on clarify with the ordering physician, then the computerized medication delivery systems must be equipped with further safeguards to prevent the accessibility of harmful amounts of drugs. That is, as soon as the Pyxis could read that that much Dilantin was signed out in a short period of time or under one patient's name, it should have locked the nurse out or alerted the pharmacy department. Any other suggestions?

the pyxis are fine. they dont have to be reprogrammed or something. if they do that they might take some of our $$$ /less paycheck!! stop blaming the machine. if you take that responsbility away from the nurses (that is, making sure youre taking out the right number of vials) then we shouldnt be called nurses anymore.

i feel sorry for the nurse and to the victim. did the doctor charted 800 mg legibly. always check with other nurse if we are unsure.

ShiTzu-The Pyxis aren't fine. Have you checked the latest national med error stats lately? They're atrocious. Whatever patient safeguards can be put into place to prevent errors is appropriate. These computerized access machines can be programmed to question or withhold the withdrawl of large or inordinate amounts of drugs. The status quo is obviously not acceptable.

whatever happened to PERSONAL RESPONSIBILITY??? whatever happened to the Professional Licensed Registered Nurse? Whatever happened to patient advocacy? WE HAVE BRAINS, PEOPLE. I personally resent it being necessary to have a machine do my thinking for me. If you don't know the proper dose, then you surely don't know the indications, contraindications and side effects. WHAT MACHINE IS GOING TO DO THAT FOR YOU? Think, people. Why bother even having RN's if we can't do our job? Might as well staff the place with CNA's.

Where in the world was this nurse's common sense? Come on, this is a god awful amount of Dilantin. 8000mgs????

I've been out of the field for some and I know that I know better than that GOD bless her and that family


nursinghome

ERERER-Solely relying on the personal responsibility of the nurse is not working. Granted, not all med errors are the nurse's fault entirely-many are generated by the physician and the pharmacist. However, nurses do shoulder most of the blame because, ultimately, we are the ones doing most of the administration. I worked in a well-known metropolitan NICU in the 80's where a nurse colleague administered a fatal overdose of Digoxin. The charge nurse confirmed the fatal dose before it was given. The only consolation to this poor family was that they had twins-at least they got to take one baby home. Both nurses were fired. I don't know if the family sued, or not. In a surgery department I worked at a few years ago, our PACU Pyxis would query if the patient was on anticoagulant therapy when we were withdrawing Toradol- just an added safeguard to the patient. When it comes to patient safety, nurse's egos need to take a back seat.

I agree that there needs to be safeguards and double checks, red flags and alerts. My concern is what I am seeing in the last few years: nurses giving meds and not knowing what they are. Being in charge, I keep an eye on what's ordered, and, occasionally will see just how far a nurse will go before questioning the med (Nitro when BP is low, beta blocker when bradycardia). I am saddened by the state of the art of nursing today, in general. Before I get blasted, I don't mean all nurses. I hate lazy more than I hate stupid.