Med Errors

[UM Review RN]

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.

[KRVRN, BSN, RN]

New NICU (with PICU experience) gave a small preemie his oral NaCl med, but gave 15cc of solution instead of 0.5cc of solution. The mistake was discovered when she was about to do it to another pt and happened to comment to another nurse that "they should make these bottles bigger!" First baby ended up having most of his gavage feeding (with NaCl mixed in) aspirated and so his Na level only went to 155. Had some gut issues a day or two later but it's hard to link that for sure since preemies can get that anyway.

A few weeks later the same nurse somehow failed to notice that her baby's isolette was off and unplugged. The next-shift nurse found the isolette off and the baby's temp at 94. Chances are the isolette hadn't been on for the entire shift because the bed had just been moved immediately prior to the start of the bad nurse's shift. So either she hadn't noticed the isolette was off all shift or she unplugged it herself! Said nurse had been charting normal temps all shift long (Q3hr), including one that was within 3 hours of the 94 temp. Obviously falsified.

She wasn't fired, but was asked to leave and she did. Makes you wonder why she left her PICU job.

[KRVRN, BSN, RN]

We used to keep stock bottles of heparin flush in the med fridge for all to use for flushes. If we had a baby on vecuronium, that nurse would reconstitute an entire bottle and it would also stay in the fridge for intermittent dosing.

Well, it was a matter of time. Our heparin flush labeling was changed one day (pharmacy using a different brand or something) and it was just a little too similar to the vecuronium labeling. The same nurse (a good nurse with years of experience) flushed heplocks on 2 NON-INTUBATED babies with vecuronium. The error was obvious since it happened to both babies within 5 minutes of each other. Both babies were fine. The nurse was devastated.

Now we no longer have a stock bottle of heparin flush and vecuronium is only released from the pharmacy PRN for a specific baby in syringes.

[mattsmom81]

Gosh I could write a book of things I've caught/found or had happen to me or coworkers. We are ALL human. Working nights and doing 24 hr chart checks has been an education...LOL!! I've caught whole pages of missed meds, orders, transcription errors, handwriting errors, you name it.

I've found:

Krider given wide open through a Swan Ganz sideport...resulting in Vtach.

High concentration Heparin in aline flush system...resulting hemmorhage.

Two patients potent cardiac meds completely mixed...a nurse under my supervision caught her mistake, admitted to it thankfully. One became hypotensive and bradycardic requiring fluid resuscitation and ACLS meds. The other one needed meds tweaked for dysrhyhmia due to the wrong meds earlier. If she hadn't told us they could have arrested before we caught the problem (tele unit not ICU) so we were able to monitor closely. Surprisingly, the cardiologist did NOT tell the patient the nurse screwed up. The patients were OK in the end, the nurse was counseled but not fired...as she was honest. (happy ending)

Student nurse gave PEG meds into CVC. Pt died. Nursing instructor (who was supposed to be supervising) was off the unit and the hospital blamed the primary nurse and fired him. He was a friend of mine. Nothing happened to the student who failed to obtain required supervision.

Nurse and pharmacist both misread order for .5 mg Ativan IV, gave 5 IV...pt respiratory arrested. The MAR dose was unquestioned, entered by pharmacy as 5 mg IV Ativan. Which is why we ALL have to be double checks for each other...even pharmacy makes mistakes and has brain farts. I could tell a hundred tales of this type thing.

[cannoli]

Gosh I could write a book of things I've caught/found or had happen to me or coworkers. We are ALL human. Working nights and doing 24 hr chart checks has been an education...LOL!! I've caught whole pages of missed meds, orders, transcription errors, handwriting errors, you name it.

I've found:

Krider given wide open through a Swan Ganz sideport...resulting in Vtach.

High concentration Heparin in aline flush system...resulting hemmorhage.

Two patients potent cardiac meds completely mixed...a nurse under my supervision caught her mistake, admitted to it thankfully. One became hypotensive and bradycardic requiring fluid resuscitation and ACLS meds. The other one needed meds tweaked for dysrhyhmia due to the wrong meds earlier. If she hadn't told us they could have arrested before we caught the problem (tele unit not ICU) so we were able to monitor closely. Surprisingly, the cardiologist did NOT tell the patient the nurse screwed up. The patients were OK in the end, the nurse was counseled but not fired...as she was honest. (happy ending)

Student nurse gave PEG meds into CVC. Pt died. Nursing instructor (who was supposed to be supervising) was off the unit and the hospital blamed the primary nurse and fired him. He was a friend of mine. Nothing happened to the student who failed to obtain required supervision.

Nurse and pharmacist both misread order for .5 mg Ativan IV, gave 5 IV...pt respiratory arrested. The MAR dose was unquestioned, entered by pharmacy as 5 mg IV Ativan. Which is why we ALL have to be double checks for each other...even pharmacy makes mistakes and has brain farts. I could tell a hundred tales of this type thing.

I hope your friend got himself a lawyer.

[weetziebat]

Student nurse gave PEG meds into CVC. Pt died. Nursing instructor (who was supposed to be supervising) was off the unit and the hospital blamed the primary nurse and fired him. He was a friend of mine. Nothing happened to the student who failed to obtain required supervision.

Yeah, I also hope he got himself a lawyer. The student nurse knew he had to have supervision, so unless he asked the primary nurse and was told by him to go ahead and give it unsupervised, how could they possibly fire the nurse - and not do anything to the student. Wow! totally unfair.

[RN30years]

I worked on a tranfusion team for over 10 years.

PRBC's are not needed for a Hb above 6 and maybe not then, at times they cause more problems than they solve. New cells into a compromised body don't allways help

[UM Review RN, ASN, RN]

I worked on a tranfusion team for over 10 years.

PRBC's are not needed for a Hb above 6 and maybe not then, at times they cause more problems than they solve. New cells into a compromised body don't allways help

This is why I'm finding this thread so interesting. Generally, our hospital proceeds with thinking about transfusing Hgbs below 9, and we usually do if

Of course, different hospitals have different policies, so remember to defer to your hospital policy.

[kitty=^..^=cat]

This is such a great thread -- I've worked as a risk manager and director of QRM for the better part of the last ten years, and I believe that it's important for us to discuss our errors in a safe environment. In reading through this thread, it's clear that new requirements from JCAHO and the recommendations of the Institute for Safe Medication Practices are a lot more in line with "real world" problems than what I first thought the first time I saw the "never use" abbreviation list...

I've seen a lot of medication errors --

An entire 500 cc heparin drip infused over about 30 minutes - the nurse thought she was bolusing saline;

100 units of insulin administered instead of 10 - the physician wrote 10 "u", which was interpreted as another zero on the end. The nurse didn't question it, and it was given before the pharmacist reviewed the order.

Countless antibiotics administered greater than 4 hours after admission - this is a biggie now with the Medicare people and their pneumonia initiative (just an FYI in case that's going to be one of your facility's publicly reported stats...)

Thrombolytic given to a patient only suspected of having a PE - she died from bleeding complications;

Medications given PO to an intubated patient - the nurse deflated the cuff and administered them by mouth;

IV contrast administered PO;

And the list goes on and on and on...

One thing I've noticed throughout my career from staff nurse in a number of settings to my current role as DON is that nurses too often have been held solely and individually accountable for system/process problems. How many times have wrong medications been administered because there was no process in the pharmacy to assure that the correct meds were being put into the cart cassette? How many physicians' crappy handwriting have resulted in wrong meds/doses/etc. -- and how many pharmacists and nurses have been blamed for not being able to read completely illegible orders? How many medication administration processes are so convoluted on paper and in reality that one needs an atlas and a mining helmet to make her way through it then ends up free-wheeling it because there's no clear expectation of the steps in the process?

I apologize for the length of reply, but this subject is one of my favorite soapboxes...

[mattsmom81]

I worked on a tranfusion team for over 10 years.

PRBC's are not needed for a Hb above 6 and maybe not then, at times they cause more problems than they solve. New cells into a compromised body don't allways help

This is not true for many patients who are relying on the oxygen carrying capability of hemoglobin due to disease processes.. We mustn't generalize. Each patient should be looked at individually.

[RN30years]

You are right. Each pt must be looked at individually.

I was generalizing.

But many times Blood Products are wasted.

I have seen it time and time again. Many Pt's who have suffered blood loss due to surgery actually do better if not transfused. The body is working so hard to accomadate all the new antibodies after a blood product is transfused that is actually slows the healing process. Some Doc's argure that a couple of days of O2 is actually better than transfusing.

There are many Pt's with disease processes that and transplant pts.

truely need blood product transfusion

[RNKITTY04]

We just had a staff meeting yesterday were it was stated we can no longer take an order that reads "xxxx prn med given 4-6 hours" we must have an exact time q4 and the Doc must state if the med is for pain or whatever. We also can't have an order that says 1-2 tabs, it must state exactly how many tabs.This should be fun getting the Doc to nail down an exact time for PRN meds.

[stevierae]

Many Pt's who have suffered blood loss due to surgery actually do better if not transfused. The body is working so hard to accomadate all the new antibodies after a blood product is transfused that is actually slows the healing process. Some Doc's argure that a couple of days of O2 is actually better than transfusing.

Crystalloid works wonders, too. Sometimes all that is needed is volume replacement.