For our collective benefit, list some of the med errors you've seen committed or caught before they were committed.
The only rules are:
1. No blaming.
2. No naming names.
3. State what the error was.
Examples:
1. Mag and KCl hanging without a pump. ---Both need to be administered on a pump.
2. Regular insulin, pulled up in mg's, not units ---Self-explanatory.
3. Digoxin 0.125 mg po qd ----Given with an apical HR of 42.
4. Order for Vistaril IV ---Never give Vistaril IV.
5. Lopressor 25 mg po bid, 1 tab ----Pt. got 50 mg. because this med only comes in 50 mg tabs and should've read "1/2 tab."
6. PRBCs hung over the 4 hour limit. PRBCs piggybacked into ABTs. ---PRBC total hang time may not exceed 4 hours. This might include time taken from the blood bank in some facilities. ---Never piggyback anything into PRBCs.
7. PRBCs not hung for over 24h with a Hgb of 6.8.
8. "Demerol 100 mg. IVP q2h prn" --Classic case of "too much, too soon."
9. "Percocet 1-2 tabs po q4h prn, Darvocet N-100 1-2 tabs po q4h prn, Tylenol ES gr. X q4-6 h prn" ---Tylenol can potentially exceed 4 gm/day max.
10. Dilantin piggybacked into D5. ---NS yes, D5 no.
