Patient died from 8GMs of Dilantin - page 7

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   KRVRN
    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.
  2. by   RNsRWe
    Quote from KRVRN
    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?"
  3. by   Uptoherern
    "all of us are troubled when we have a bad outcome"

    ???????????????????? corporate speak, gobble de gook. jeez, the lady died! He makes it sound like his casserole didn't come out right.
  4. by   ERERER
    Dilantin is not an unusual drug, we give it all the time in the ER. it's cheaper than Cerebyx. monitor, filter, etc. what amazes me is when a nurse gives a drug they are not familiar with without looking it up. If that nurse was familiar with Dilantin she would have choked at that dosage. I have been a full-time nurse for 25+ years and still look things up every shift. I have also stopped nurses from giving meds that should be held (beta-blockers, etc.). Just because a doctor writes an order doesn't mean it should be followed blindly. That is why nursing is a PROFESSION. we are supposed to be educated and patient advocates. unfortunately there are those who become nurses and do just the minimum required to get through the shift.
  5. by   ZASHAGALKA
    Quote from KRVRN
    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.
    On the comments section of the local paper's online story (linked in the OP), several employees of Broward General stated that the order entry is computerized and designed specifically to eliminate illegible orders and I believe, orders with trailing or leading zeros as well.

    The doc typed this order into a computer; it was not handwritten.

    "at bgmc, orders are entered into a computer-completely legible."



    ~faith,
    Timothy.
    Last edit by ZASHAGALKA on Feb 2, '07
  6. by   canoehead
    I've been thinking about this for days, and 32 vials.....? I can't understand it. I don't think our pharmacy has 32 vials of anything, let alone our unit.

    I had to give 11 vials of mannitol, and checked with the book, the other nurse, and the doc before I gave it. Even so, the other nurses saw 11 vials on the counter and started checking on their own too. There is no way anyone could get away with 32 vials in plain sight and not be questioned in our hospital.
  7. by   flashpoint
    Wow...HUGE error. I've seen 3000 mg of dilantin given and the nurse who gave it clarified and confirmed it with everyone from the doctor to the nurse manger to the pharmacist and even called a neurologist in Denver before she did it. The patient had 1:1 care, telemetry, and repeated EEGs too. I would be very curious to know how long it took her to infuse that much Dilantin...
  8. by   NoMoreStudying
    I'm curious what her defense would be. Not to insult, but even an adolescent would think twice about that many vials. I've been confused by the concentration listed on a vial, but you stop and think.
  9. by   flashpoint
    Quote from NoMoreStudying
    I'm curious what her defense would be. Not to insult, but even an adolescent would think twice about that many vials. I've been confused by the concentration listed on a vial, but you stop and think.

    Exactly...I mentioned to my husband that this nurse gave a patient 32 vials of dilantin and my 9 year old daughter stopped playing her video game to ask, "Shouldn't she have known it was wrong if she had to use more than one?" Pretty logical thinking for a 9 year old.
  10. by   edsdcs
    wow, 32 vials! that should have alerted the nurse alone.
  11. by   kstec
    Before becoming a LPN I worked in a hospital pharmacy for 14 years. Because we are all human I realize we make mistakes, but if I had received a label to compound a IV with 32 vials, I would of been very alarmed and questioned that. Medications are usually dosed so that you don't have to use 32 vials of anything. Since I worked in pharmacy for so long, I became familiar with normal doses of medications, so if something seemed odd, I would not hesitate to question the pharmacist who entered the order, or go look at the order myself. Also someone made a good point that this nurse would of had to search high and low for that many vials of Dilantin. I know with our pyxis machines they would not hold that many in one drawer, unless she called pharmacy for a refill and she depleted to original amount. Not that I think nurses aren't capable of admixing their own medications, I think having the extra area of checks and balances by having pharmacy mix up most if not all medications. They to make mistakes but with the heavy load that nurses have on them already that is just one less thing that have to do.
  12. by   Hi_r_ed as RN
    I agree with all the comments.Its really a tragedy on all concerned.
    The doc...,the family..., and even the NURSE.

    I am sure she cant be happy whereever she is at this point.That must haunt her every day.Wonder if she is comfortable practicing now.

    My concern though is the pyxis system...Shouldnt it be able to identify when the dosage is incorrect for a particular pt? This is a computerized system.It should be able to block a nurse from getting in excess of the correct dose for a particular pt.

    In my mind once the pharmacist profiles the correct dosage, once the maximum is taken out then the nurse shouldnt be able to get any more of the medication.

    We are living in a computerized age and so we should maximise the use of these computer systems to minimize errors of this nature.
  13. by   ERERER
    The pyxis, the pharmacist, the doctor, the system. WHATEVER. Whoever is injecting a drug into a patient has the ultimate responsibility to know what they are giving. and what is appropriate. If they don't, it takes 5 minutes to look something up. I have NEVER worked in a place that didn't have some kind of drug reference book. There is a reason that nurses are licensed, educated, trusted. If you are practicing "blind" nursing, then maybe you should get out. If YOU are the one carrying the medication to the patient, then YOU are the one responsible for their safety, I don't care how busy it is. You have a duty as a PROFESSIONAL.

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