Patient died from 8GMs of Dilantin - page 9

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   mellendis
    common sense isn'y so common after all
  2. by   Boston Blackie
    Having been a Registered Nurse for many years, I have the utmost respect for the Nursing Profession. In my response I was not critizing the Nursing Profession-May God Bless & watch over all of them-my concern is with our system that continually changes, taking away the resources e.g. - enough Nurses & staff to give the proper amount of time to carry out their work. The pressure is driving Nurses from their beloved Profession. We probably will never know why that Nurse missed all the Red flags & her reasoning was absent- overwhelmed?? Burned out??? The A.N.A., as hard as they work to solve the problems, can only do so much. The fight is not over yet!
    "Have a Heart that never hardens, a Temper that never tires & a Touch that never hurts" Addison
    Last edit by Boston Blackie on Feb 8, '07 : Reason: To add quote
  3. by   psychRN33
    Clearly the nurse could be charged with malpractice. She was unable to perform at a level comenerate with an RN. This experience clearly points out the necessity for nurses to be familiar with the typical doses for the meds that they dispense. If not, they need to to find the information before dispensing the drug. One of the easiest and most accessible ways to get this information is to do a Internet search on the drug name.
  4. by   ERERER
    "At any rate, the pyxis system should be revamp to prevent this sort of error. "
    I STILL think that the main point here is being missed. I don't give a damn what kind of med access system you have. If you are injecting a drug into a human being YOU are responsible for knowing the usual dose, indication, and side effects of that drug./ Whatever happened to personal responsibility? This whining about a computer system protecting us from errors makes me nauseous. Nursing is a PROFESSION, we are not waitresses. Outside of a code, which your ACLS should have prepared you for, You always have time to take 3 minutes to look up a drug you are unfamiliar with. Most of the drug errors committed are from laziness. I'm sorry to say, I'm fed up with the direction that nursing has taken this century, blaming someone else for your errors. That nurse should be in jail.
  5. by   jwl300
    My thoughts are summed up with:

    language barrier

    If the nurse is from Jamaica, maybe she didn't hear the doctor correctly if it was verbal. Dialects can make understanding a challenge. Which is where was the concept of time out and reading back what the doctor said? Maybe he told her: xxxx mg's as he was writing and she never viewed the written order? No, it doesn't make it right, but how many times have orders been taken without a proper readback?
  6. by   moonrose2u
    ok. i am curious...what hospital did this occur in? i couldn't find the news story on the internet...
  7. by   ERERER
    the first message in this thread has a link to the news story, I believe it was Broward General in Fort Lauderdale
  8. by   dogwalker
    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?
  9. by   shihtzu
    the pyxis are fine. they dont have to be reprogrammed or something. if they do that they might take some of our $$$ /less paycheck!! :chuckle 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.
  10. by   thomascarrol
    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.
  11. by   dogwalker
    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.
  12. by   ERERER
    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.
  13. by   GR8LVN
    Where in the world was this nurse's common sense? Come on, this is a god awful amount of Dilantin. 8000mgs????

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