Patient died from 8GMs of Dilantin

Apparently someone failed to teach this RN the good rule of thumb regarding medication administration.....if you have to give three or more of anything (pills, vials, etc.) and you're not COMPLETELY sure, you'd better check with a pharmacist or MD!!

I think my favorite part of all of this is that the hospital retrained their nurses on med calcs. Apparently, what they really need to do is retrain their nurses on common sense! I do think it was smart that they put a warning into the Pyxis regarding excessive dosing. I think we should have as many safeguards as possible.

Someone asked if Dilantin is a common ER drug. I have actually never given it IV - we always use Cerebyx. Much safer and easier.

There are so many reasons why this shouldn't have happened.....

On my med surg floor we are not allowed to give dilantin IV since we do not have any monitors, it is only given in the speciality units at my hospital.

I also cannot fathom drawing up that quanity of medication without bells going off in my head. Where were the other nurses in this situation and did
they notice what their co-worker was doing?

We give IV Dilantin frequently - common loading dose is 1 gram IV, or some combo of IV and PO to equal 1 gram depending on the pt's current Dilantin level. We stock it in our Pyxis, in 250mg vials. Having to mix even the 4 vials, using a filter needle, is considered bothersome by myself & many of my coworkers. Most of us will ask pharmacy to mix it & send it to us.

32 vials is just beyond my understanding. What a tragedy.

A tragedy to the patient and family, but I don't see feeling sorry for the nurse. That's why we ask for help if we need it. If she didn't realize that what she was doing was wrong, then she had no business working as a nurse. There were numerous red flags that she should have noticed and didn't.

Still shaking my head at this mistake,
Pam

I agree 100%. Duh!

I think ALL nurses should have to pass a "common sense" test before ANY nursing classes or even getting accepted into any program. I know LOTS of nurses who have trouble walking and talking at the same time. I often wonder where they went to school and how they passed their boards.

I've seen the mentality of "well, that's what the doctor ordered" --and a nurse just blindly following it. I've seen that in new nurses, medium nurses and 20+ yrs nurses. So I can imagine maybe the doctor used a trailing zero (800.0) or wrote illegibly or made a mistake and the nurse thinking, "well that's what the doctor ordered" ...and just ignoring the fact that it's a huge dose and required several vials.

Then those nurses should not be practicing, period. It was rammed home time and time again in even the fundamentals classes to check and recheck if anything whatsoever seems off. That it was OUR responsibility to follow up on anything that wasn't correct, and it was within our education to know that it wasn't correct.

Had to smile at the "required several vials"....five, or seven might be considered several. THIRTY-TWO? That's idiotic. Which is why I think that this was more than just a nurse thinking "hey, it's what was ordered" and closer to "I wonder when this fuzzy feeling from my recreational substance abuse is going to go away?"