Patient died from 8GMs of Dilantin - page 3

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   Simplepleasures
    Seems so odd that she wouldnt have confered with fellow nurses about such a wierd dosage?Or better yet paged the MD to clarify.Or pharmacy as Angie posted.
  2. by   RNsRWe
    Ok, I know this wasn't suggested anywhere as yet, but the only thing I can POSSIBLY imagine that could cause an experienced nurse to be this far off base is if she was so severely distracted, perhaps under the influence of something, that she simply could not think straight.

    There's just no other reasoning, in my mind for this scenario going through the nurse's head: "MD has just told me to give 8000 mg of Dilantin. Ok, I'll go get the med from the Pyxis. Hmmm, according to my math I'm gonna need alot more than what's here; I need 32 vials. Ok, I'll gather it all. Gee, wonder why there's only ten in this one? And only ten in that Pyxis? Man, I'm cleaning out ALL the Dilantin from the unit! Ok, have it all. Drawing up vial one.....four.....seven.....nine....gee, seems like alot of work. Drawing up vial 11.....17.....20.....24. Whew, this is taking ALOT of time! Never had to do THIS much Dilantin before. Never saw anyone else do this either. Oh, well....drawing up vial 27.....30....32! Gonna need two bags for this....and start another IV. Gosh, I hope I don't have to do this again in a few hours!"

    Which is why I can't imagine a sober, non-impaired nurse doing this.
  3. by   MrsWampthang
    Quote from RNsRWe
    Ok, I know this wasn't suggested anywhere as yet, but the only thing I can POSSIBLY imagine that could cause an experienced nurse to be this far off base is if she was so severely distracted, perhaps under the influence of something, that she simply could not think straight.

    There's just no other reasoning, in my mind for this scenario going through the nurse's head: "MD has just told me to give 8000 mg of Dilantin. Ok, I'll go get the med from the Pyxis. Hmmm, according to my math I'm gonna need alot more than what's here; I need 32 vials. Ok, I'll gather it all. Gee, wonder why there's only ten in this one? And only ten in that Pyxis? Man, I'm cleaning out ALL the Dilantin from the unit! Ok, have it all. Drawing up vial one.....four.....seven.....nine....gee, seems like alot of work. Drawing up vial 11.....17.....20.....24. Whew, this is taking ALOT of time! Never had to do THIS much Dilantin before. Never saw anyone else do this either. Oh, well....drawing up vial 27.....30....32! Gonna need two bags for this....and start another IV. Gosh, I hope I don't have to do this again in a few hours!"

    Which is why I can't imagine a sober, non-impaired nurse doing this.

    Exactly what I was thinking. No nurse, good, bad or indifferent, would have drawn up this amount if they were in their right mind. She had to have been under the influence of something and that maybe why she's not talking. If she wasn't, then she is too extremely stupid to be a nurse. I don't care how stressed or hurried you are, you MUST at all times, follow the five rights, no matter what!!!! There is no excuse for this error. I'm sorry, I don't feel anything but disgust for her, I do feel extremely sorry for the three children and the husband who now have to live without mom and wife. I agee that $200,000 seems like a low settlement in this case too, but maybe the hospital has some sort of cap or something. I don't know. I hope the Florida BON takes her license away for good so that she can never harm another patient. It's scary to think that there may be other errors she has made that no one caught. Sorry to sound so harsh, but this just hits a nerve with me. We nurses get enough grief without some moron making this kind of error and making us all look bad.

    Pam
  4. by   firstaiddave907
    Quote from MarySunshine
    I don't understand what the doctor did wrong.

    I have NO idea how she gave that much dilantin. That's makes NO sense.
    I agree with you.
  5. by   Freedom42
    Here's another newspaper's take on this story. It has a couple of tidbits that might be of interest:

    The hospital could only pay out a maximum of $200,000 to the family of the victim because it receives public funding and is protected by sovereign immunity. Anything more would require an act of the Legislature.

    The hospital claims that the nurse was not fired because of her mistake but because "it was discovered she'd tried to hide the fact that she'd dispensed all that Dilantin from so many machines."

    The hospital says its Pyxis machines now contain only one vial of Dilantin, and a supervisor is notified if a nurse tries to get vials from more than one machine at a time.
  6. by   porcelina22
    I'm in awe. Even 3.2 vials seems like a lot- granted, I'm still a student, but are are taught in school that if you need more than one vial or pre-filled syringe, you should ALWAYS clarify the order!!! At least go look up the drug!

    This just sounds like self-destruction. What nurse wouldn't stop at the first Pyxis and realize something is very wrong when the PYXIS RUNS OUT OF MEDS??? I'm curious to see if they release any info on her mental state of health.

    Chrissy
    Last edit by porcelina22 on Jan 26, '07
  7. by   rn/writer
    I can't imagine this process took anything less than a half hour and perhaps longer. The light should have gone on at some point that, just from a common sense standpoint, this "order" didn't make sense.

    Even if I thought the 8000 mg dose was correct, I would have been calling pharmacy to find out if they stocked a higher concentration so fewer vials would be needed. Or, barring that, I'd have asked them if they could send me the correct number (or if I could come get them) so I wouldn't have to be tracking down other Pyxis machines and cleaning them out. Either one should have set off the phamacist's alarm bells and the error could have been caught.

    There is no point in being disgusted with this nurse. I doubt that she got up that morning and said, "Gee, I wonder how many lives (including my own) I can ruin today." I feel a great sadness for everyone involved and an immense horror at how one stupid decision can wreak havoc in so many ways.

    What I take away from this tragic event is a renewed respect for checking, not only the five+ rights, but also ANYTHING that seems the teensiest bit hinky. At the very least, the nurse might have stopped a catastrophe in the making if she'd only shown the order to another nurse and said, "8000 mgs of Dilantin. Does that seem right to you?"

    Even if she wasn't familiar with a therapeutic amount of Dilantin, the fact that it's packaged in much smaller amounts than this "order" called for should have screamed, "THIS IS NOT NORMAL," and demanded further investigation.

    What a waste.
    Last edit by rn/writer on Jan 26, '07
  8. by   lorster
    If I would have been a nurse working this unit and I would have seen 32 vials of anything being drawn up by another nurse, I would have stepped in at least to see what they were doing. 32 vials is a lot of vials to be sitting on a counter. I'm really surprised another nurse did not say something.
  9. by   RNsRWe
    Quote from lorster
    If I would have been a nurse working this unit and I would have seen 32 vials of anything being drawn up by another nurse, I would have stepped in at least to see what they were doing. 32 vials is a lot of vials to be sitting on a counter. I'm really surprised another nurse did not say something.
    For what it's worth, when the unit is busy, someone could be drawing up practically anything at all and others would not notice: we're too busy concentrating on what WE'RE doing. When I've got an overload of patients in pain or crisis, I can't even tell you what the other nurses in the medroom, sometimes standing right next to me, are doing. I avoid mistakes by paying attention to what I'M doing.

    Unfortunately, I'm betting no one DID see this, or certainly, someone would have mentioned SOMETHING.
  10. by   GardenDove
    Frankly, this mistake is such a gross error, there really is no explanation other than incompetance. Not everything is a system error. This error would be akin to driving on the wrong side of the freeway.

    This nurse tried then to cover it up? I wonder how many other errors she didn't report over the years?
  11. by   Mimi Wheeze
    I do wonder how long it took her to draw up 32 vials.

    The pt was siezing, wasn't somebody with her for safety? Didn't anybody notice this nurse was gone for so long? I just don't get it.

    There has to be more to this story.
  12. by   Freedom42
    I don't think this was incompetence. I think this was someone having some kind of breakdown, a way to get out of a situation she just couldn't handle any more. When she realized what she'd actually done, she panicked and tried irrationally to hide it. Though it's pure speculation, I have to wonder if this nurse had mental health issues prior to this tragedy.
  13. by   leslie :-D
    this is just plain tragic, on so many levels.
    i'd be curious to learn all the facts involving this case.
    to be an er nurse for sev'l yrs and administer 8gms of dilantin, we surely do not know the whole story....
    my prayers go out to all involved.

    leslie

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