Patient died from 8GMs of Dilantin - page 12

From the Sun-Sentinel: The highlights: -ER nurse, with 9 years experience, is caring for a 44 y.o. F patient, c/o seizure with hx of same. The patient ran out of Klonopin and has no health... Read More

  1. by   little_lost_bear
    I am an American living in Australia. Here in Australia, all injections, and ivs must be checked by 2 nurses. Including doing the math for special orders. Doesn't matter what area (ECC, ICU, CCU or the wards. Even on nights when there is only 2 RNs, you still have to, if that other RN is busy you can take it across the hall to the next ward. This helps with safe gaurding things like this happening. Here also,,,,,, all peds medications must be double checked from orals to injections.

    Here we have RNs, EENs (whom does medications) and ENs (who do not do meds). You must check with either an RN or EEN. Its a pain, but it works to help prevent accidents just like this.

    And if 2 nurses can't agree on amount to give, than we get a third person or ring the Doctor to double check orders.
  2. by   ebear
    In addition to this fiasco, the doctor is filing a "wrongful termination suit"? Now that's amazing to me! IMO, he can get ready for a medical malpractice suit for which he, the nurse, and the hospital will be named.
    I see NO defense in this situation for any party. A terrible, catastrophic mistake.
    ebear
  3. by   MnemonicFanatic
    I have been reading the posts, and as a current nursing student (3rd semester out of 4). This is just a reinforcement as to why we are told over and over again to check and recheck orders, meds, dosages, patients, et al.

    I have been trying to find the original article, however since the incident happened so long ago, the newspaper's website doesn't have access to it anymore.

    Does anyone know where I can find the article? I want to bring it in for discussion...
    Thanks!
  4. by   EmmaG
    Quote from MnemonicFanatic
    I have been reading the posts, and as a current nursing student (3rd semester out of 4). This is just a reinforcement as to why we are told over and over again to check and recheck orders, meds, dosages, patients, et al.

    I have been trying to find the original article, however since the incident happened so long ago, the newspaper's website doesn't have access to it anymore.

    Does anyone know where I can find the article? I want to bring it in for discussion...
    Thanks!
    Full text on the first post here: http://www.emrupdate.com/forums/p/8306/62217.aspx

    I must disagree with my friend above; that doc did nothing wrong. The nurse, on the other hand...

    Sheesh. At what point when you're pulling up 32 vials of anything do you stop to think, "Gee, something just doesn't seem right here..."

    I walked in the med room to find one of our nurses pulling up vial after vial of Hepflush. Syringes everywhere. When I asked what the heck was she doing, she said she had a new order for 5000 units of SC heparin. That's when you just wanna :trout:

    :stone
    Last edit by EmmaG on Nov 2, '07
  5. by   rnmomtobe2010
    this is unbelievable. i was having an ok day until i read this. i know this is old but my goodness I do know that it is also the nurse's responsibility to double check orders after they are given. That is not even right.
  6. by   TrudyRN
    Perhaps the real crime is that a patient can't afford his medication. If he had taken the med, he'd have not been in the ER to begin with.

    Shame on America and the money-grubbing vermin who put their own wealth before everyone's health.
  7. by   EmmaG
    Quote from inshallamiami
    I recently spoke with a RN who was working in that ER when that happened. She told me that the nurse who gave the dilantin was a know it all and that she and others had noticed her with all those vials! [evil]Evidently they did nothing![/evil] Real Nice.
    So they allowed her to kill a patient in order to teach her a lesson.

    They should be prosecuted as accessories to murder.
  8. by   danissa
    Quote from inshallamiami
    I recently spoke with a RN who was working in that ER when that happened. She told me that the nurse who gave the dilantin was a know it all and that she and others had noticed her with all those vials! [EVIL]Evidently they did nothing![/EVIL] Real Nice.
    How shocking is that??? Disgusting people! i do hope they also pay for their part in this.
  9. by   cardiacRN2006
    Quote from Emmanuel Goldstein

    I walked in the med room to find one of our nurses pulling up vial after vial of Hepflush. Syringes everywhere. When I asked what the heck was she doing, she said she had a new order for 5000 units of SC heparin. That's when you just wanna :trout:

    :stone

    Oh my goodness! I can just imagine this happening. And was she still going to give all that fluid SC???
  10. by   kmm1234
    I have a hard time understanding a nurse that would go get that much Dilantin and not relize she was making a mistake. As for those that saw this happen and said nothing, I agree that they should be held accountable as well. I had a similer experience with insulin years ago. The patient was to get 4units of Regular and the nurse drew up 40units. Thank God she followed protocol and had a second nurse, myself, check behind her. I know it is hard to point out others mistakes because when this happened to me I was not sure what to say at first but when a patient's life is at risk you don't keep you mouth shut. I don't care how much of a know-it-all she might have been. The nurses that stood by and watched are at fault as much as the nurse giving the medication in error. That is not just mean but a patient died and that should be on everyone's heart.
  11. by   EmmaG
    Quote from kmm1234
    The nurses that stood by and watched are at fault as much as the nurse giving the medication in error.
    More so, IMO. There's nothing to indicate the nurse was malicious in committing this error. These others stood by and watched it happen and yet didn't intervene. Calling her a "know-it-all" implies there was some satisfaction in watching her make a mistake and that they knew the mistake was a big one. So their actions were malicious, and I think that they should not only lose their licenses but be criminally prosecuted as well.
  12. by   CraigBSN02
    Wow, this thread is still going! :-)

    I remember someone asking where to get a copy of the article in question. Since it's almost 2 years old, you can only purchase the article from Sun Sentinel. Try this link:

    http://tinyurl.com/3bcyux

    The cost is $3.95, not too bad.
  13. by   danissa
    Quote from Emmanuel Goldstein
    More so, IMO. There's nothing to indicate the nurse was malicious in committing this error. These others stood by and watched it happen and yet didn't intervene. Calling her a "know-it-all" implies there was some satisfaction in watching her make a mistake and that they knew the mistake was a big one. So their actions were malicious, and I think that they should not only lose their licenses but be criminally prosecuted as well.
    :yeahthat: Totally!!!! Well said Emmanuel! absolutely makes your blood boil reading about their actions/omissions doesn't it! Wonder if these accesories can face themselves in the mirror in the morning, or sleep at night? how unfortunate that these are supposedly fellow nurses. :angryfire

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