Errors that you caught... - page 3
Hey Guys, Out of pure curiosity, what is the worst/scariest potentially harmful error that you have caught, and what did you do to rectify the situation? What happened to the person who did the... Read More
Aug 4, '12New nurse that I worked with did not know that secondary IVs needed to be connected to a Y site above IV pump in order to control rate of flow & hung a potassium fast drip piggy-backed it into a Y site below the pump. Pt subsequently began complaining of burning on the arm the PIV was located in, as is common for a lot of pts due this drug being a vesicant. I began to explain to her how to further dilute the drug with a 50cc bag of NS & a double pump when the pt began to yell out in extreme pain. I then discovered the error & the fact that the pt had received nearly the entire 10 mEq dose of potassium in about 10 minutes. Luckily no permanent harm was done to the pt, the nurse felt extremely bad, was re-educated on secondary IV medication, & to my knowledge never made the same mistake again.
Aug 5, '12We mainly do out patient surgery and some GI procedures.
Our surgery patients get LR, our GI patients get D5 LR. I relieved a nurse for a coffee break and she said her patients glucose remained high (not dangerously high, just high) in spite of giving her insulin.
She had had a mental moment and forgotten it was a GI patient who still had the D5 LR running. I changed it to LR and all was fine.
Aug 5, '12As a student, one day when I got to clinical, our instructor gave out our patient assignments and told me my patient was on a heparin drip, here's the facility policy, review it and go check your pt. So I did, went in to eyeball my pt who was sleeping and just because I "LOVE" math (smell the sarcasm) I worked up the problem on my bad boy. Hmmmm, what I got was NOT what the pump was set for. OK, do it again. Nope, same answer.
OK, so I went to get the RN assigned to this client and told her I had a question, could she help me. She said sure and into the pt's room we went. I explained what I had done math-wise and how it didn't match the pump. She sets up her math differently than me, so we did it her way and mine, yup, same answer. My client was being over-medicated. There was also a "cheat sheet" attached to the pump for things like this. Turns out that the card was for 50,000 unit bags and the one hanging was a 40,000 unit bag. And yes, heparin is a double check medication, both nurses checked it wrong when it was hung.
So the RN and I went to the charge nurse who, get this, blamed it on pharmacy for switching from the 50000 bags to the 40000 bags!!! And she was pizzed b/c "now those cards are going to have to be re-done for all the pumps in the hospital"! WTH?! My RN took me aside and told me it was a great "catch" and I would make a wonderful nurse someday with attention to detail like that.
My instructor was also pretty pleased that one of her students caught such an error.