Med Errors

  1. 3
    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.
  2. 210 Comments so far...

  3. 1
    Our policies allow us to hang a liter bag of fluid with 20 of KCL in it to gravity, but no more than 20 meq's.

    I've seen 100 mg. IV Demerol q2h ordered before on a chronic sickle cell patient and he tolerated it just fine.

    Now to answer your post:

    I've seen a nurse give a handful of meds to the wrong patient and she denied it.

    I've seen phenergan given IV when the nurse thought he was grabbing a normal saline flush he also drew up at the same time.

    Rumor has it a nurse crushed up Percocet and gave it IV through a central line.

    Wrong dose of chemo therapy killed a child

    Scarey stuff. I'm sure I could think of more.
    DeLanaHarvickWannabe likes this.
  4. 0
    Thanks for your response, Tweety, that's exactly why I posted this thread. I'm always learning things from this board.

    Anyhow, to respond:


    Our policies allow us to hang a liter bag of fluid with 20 of KCL in it to gravity, but no more than 20 meq's.
    Sorry, I should've specified--this was a KCL bolus of 20 mEq's in 100 ml's of NS. My bad. Our policies are the same.

    I've seen 100 mg. IV Demerol q2h ordered before on a chronic sickle cell patient and he tolerated it just fine.
    The nurse in this instance (for whatever reasons I don't know offhand) questioned the dosage frequency to the Pharmacist, who recommended questioning the order. The order was changed. The patient was moved to another unit, where the order was changed again, back to the original. The med was given per order--and the patient subsequently went into convulsions, possibly from the metabolites in Demerol. (Is it possible that this Pt. had cirrhosis or something else that would cause an intolerance to the metabolites?)

    At any rate, I now get very nervous when I see high, frequent doses of Demerol prescribed... :uhoh21:
  5. 2
    You can't give Vistaril IV? Huh, it SEEMS like we used to give it all the time--in combination with Demerol--in very early labor for pain relief (granted, this was back in the '70s, before anyone had even HEARD of epidurals.) Maybe my memory is faulty, and we gave it IM.

    I can't say I've even seen Vistaril used in any operating room setting, even IM, since Versed became available--but I have heard it is still used in ER settings for migraines--perhaps also in combination with Demerol.

    What's the reason that it should not be given IV?

    OK, maybe 5 years ago, I was circulating on a D&C for retained placenta. We had a Pitocin drip going to control the resultant post-partum hemorrhage, but her uterus remained boggy, and just wouldn't clamp down.

    The anesthesiologist resident attempted to give Methergine IV. I stopped him and offered to give it for him I.M. in the deltoid, (and did so) because I was trained to never, ever give Methergine I.V.--as its effect is on the smooth muscle of the uterus, it should be given I.M., and, in fact, since the lady was already up in stirrups undergoing a D&C, the ideal route would have been to have the surgeon inject it with a spinal needle directly into the uterus, or even paracervically.

    Now, I've since learned that you CAN give Methergine I.V. but it's not recommended except as a last resort, because it can preciptiate a hypertensive crisis or even a CVA. Anresthesiologists tend to give everything rapid IV push, and I shudder to think what this lady's outcome would have been had he proceeded to do so.

    How about the rest of you? Have you ever seen Methergine given I.V.? Could it have just as easily been given I.M. in the situation in which you saw it done, and did the patient suffer an acute hypertensive crisis?

    We also had to give this lady Hemabate and transfuse her.
    Last edit by stevierae on Nov 30, '04
  6. 1
    I saw a nurse run Magnesium sulfate at 125 cc/hr on a pt for PIH, order was for 2 g/hr which would be 50 cc/hr how we mix it. The LR that was hanging with it was to run at 125 cc/hr. Lesson: Label your lines!!
    fiveofpeep likes this.
  7. 0
    I might not be following the rules, but:
    1) regular insulin 20 U SQ for accucheck of 272. I challenged the order and it ended up going before the med director who although he was a MD didn't know what ibuprofen was. End result was that the MD ordered 10 units and recheck in 1 hr. I gave the 10 U and just before I left we rechecked the accucheck and it was 243. MD was notified and he started acting all cocky thinking he was right (saying something along the lines of 243...should I give more insulin or not...give more insulin or not), so he ordered the other 10 U. I didn't give it, but one of the other nurses did. The next day I found out that his blood sugar went down to 53 from the 2nd dose. I sooooo wish I coulda been there to do the gloating after the 2nd dose (should I kill the pt. or not...kill the pt. or not? hmmmmm) because I wasn't going to give the 2nd dose of 10 U either. Funny thing was that this MD claimed to be a endocrine specialist. :stone

    2) klonopin 1.5mg instead of valium 15 mg

    3) b&o supp 60mg instead of the 30mg one...believe me this was a very easy mistake to make; also my first med error as a RN; pt originally had the 60 mg supp, but it was lowered to 30mg because pt became delirius throughout the night; luckily my error did not cause the same side effects

    4) 8 tabs of ultram 50 mg (not my error)
  8. 0
    Quote from stevierae
    You can't give Vistaril IV? Huh, it SEEMS like we used to give it all the time--in combination with Demerol--in very early labor for pain relief (granted, this was back in the '70s, before anyone had even HEARD of epidurals.) Maybe my memory is faulty, and we gave it IM.

    I can't say I've even seen Vistaril used in any operating room setting, even IM, since Versed became available--but I have heard it is still used in ER settings for migraines--perhaps also in combination with Demerol.

    What's the reason that it should not be given IV?

    OK, maybe 5 years ago, I was circulating on a D&C for retained placenta. We had a Pitocin drip going to control the resultant post-partum hemorrhage, but her uterus remained boggy, and just wouldn't clamp down.

    The anesthesiologist resident attempted to give Methergine IV. I stopped him and offered to give it for him I.M. in the deltoid, (and did so) because I was trained to never, ever give Methergine I.V.--as its effect is on the smooth muscle of the uterus, it should be given I.M., and, in fact, since the lady was already up in stirrups undergoing a D&C, the ideal route would have been to have the surgeon inject it with a spinal needle directly into the uterus, or even paracervically.

    Now, I've since learned that you CAN give Methergine I.V. but it's not recommended except as a last resort, because it can preciptiate a hypertensive crisis or even a CVA. Anresthesiologists tend to give everything rapid IV push, and I shudder to think what this lady's outcome would have been had he proceeded to do so.

    How about the rest of you? Have you ever seen Methergine given I.V.? Could it have just as easily been given I.M. in the situation in which you saw it done, and did the patient suffer an acute hypertensive crisis?

    We also had to give this lady Hemabate and transfuse her.
    Stevierae . . . I was thinking the same thing about Vistaril . .

    steph
  9. 0
    What's the reason that it should not be given IV?
    As near as I can figure, Vistaril IV or SC can cause neuro damage.

    From http://www.healthdigest.org/drugs/hy...ochloride.html



    "Contraindications: Pregnancy (especially early) or lactation; treatment of morning sickness during pregnancy or as sole agent for treatment of psychoses or depression. Hypersensitivity to drug. IV, SC, or intra-arterially. "

    "Side Effects: Low incidence at recommended dosages. Drowsiness, dryness of mouth, involuntary motor activity (rarely, tremors and convulsions), ECG abnormalities (e.g., alterations in T-waves), dizziness, urticaria, skin reactions, hypersensitivity. Worsening of porphyria. Marked discomfort, induration, and even gangrene at site of IM injection. "

    Here's another site where apparently Vistaril was administered SC instead of IM, with pretty disastrous results:

    http://www.nursinglaw.com/injection1.htm

    "For several weeks afterward, the patient had hip pain and a lump at the injection site. The patient claimed she was unable to work. A neurologist two months later formed a diagnosis of cutaneous gluteal neuropathy...the patientís injury could have been caused by a faulty subcutaneous rather than deep muscular injection of the drug Vistaril, or that a nerve could have been hit by the needle tip due to inaccurate location of the injection site."

    Hope that helps.
  10. 0
    OMG...how could I forget...MD I previously mentioned wrote an order declaring pt was allergic to tylenol, then a week or so later wrote an order for tylenol 1000mg PO TID. wrote him up for that too.
  11. 1
    klonopin 1.5mg instead of valium 15 mg
    Well, that was a dilly, wasn't it? I would love to have been a fly on the wall of that thought process. :spin:
    Spritenurse1210 likes this.


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