Teen dies from Med Error in Labor

[htrn]

The newspaper article (I will keep looking for the link for the article) said she accidently hooked up the epidural bag instead of the pennicillan bag for IVPB, she started seizing and died 2 hours later.

Apparently the pt. was very nervous about her epidural, the nurse took the epidural bag out of the pump and showed it to the patient. She apparently set the epidural bag right next to the IVPB bag of penicillan she was going to hang and got them confused.

The hospital uses a bar code system for meds, supposed to scan the med, nurses ID badge and the med before giving the med. Patient's ID band was not on the patient but still in the chart.

here's a TV link:

http://www.channel3000.com/editorials/9508296/detail.html

I feel bad for the family, but also feel terrible for the nurse who has been put on administrative leave. This could also impact the hospital's medicare standing as well.

[zcl12]

This error has happened twice on our unit in the last year! Our epidural bags have bright pink stickers on them, these nurses were just in a hurry and very busy and forgot the five r's. THANK GOD NOBODY DIED. We are now looking into having anesthesia removing the bags without the rn or going to a syringe system. I feel bad for the nurse, unfortunately mistakes happen. I feel worse for the family however.

[Spidey's mom, ADN, BSN, RN]

We don't have epidural bags. The CRNA places an epidural, pushes the med and leaves. In order to re-dose when it wears off, we call the CRNA or the doc.

Maybe that is a good idea. . . . . .

steph

[SmilingBluEyes]

Steph, I beg to differ. Where I worked when this was done (initial infusion/bolus of epidural followed by re-bolusing PRN) way too often, the epidural wore off by the time the CRNA/MDA got around to re-bolusing and like the proverbial snowball rolling downhill, the pain got way out of control and often, was never brought back under control again.

I like continuous infusions. They are usually very reliable and require little to no tinkering after initial placement. Boluses of medication always carry risks, inherent with initial placement. You have to watch the vital signs and FHTs very closely afterward, cause you will often see hypotension and resulting FHTs decels. Smaller, continous doses are much safer.

Continuous infusion plus educated use of PCEA is the way to go, from where I stand.

[Danianne]

I have to say that it is really sad that errors like this can happen. I am a CNA and if I made an error that caised harm to a resident then it is MY fault and I would not LET the R.N. take any responsibility. Our facility just started to use the barcode system. I have had med erros happen to me personally (student) gave me tylenol#3 instead of reg tylenol even though my chart stated allergy to coedine and I had a massive bad reaction, also I had a bad kidney infection and told them I was allergic to Cipro and they "knocked me out" hung bags of Cipro for three days and were wondering why I was covered in hives and scratching my body until it bled. mistakes happen BUT try to avoid it when you can :)

[Spidey's mom, ADN, BSN, RN]

Steph, I beg to differ. Where I worked when this was done (initial infusion/bolus of epidural followed by re-bolusing PRN) way too often, the epidural wore off by the time the CRNA/MDA got around to re-bolusing and like the proverbial snowball rolling downhill, the pain got way out of control and often, was never brought back under control again.

I like continuous infusions. They are usually very reliable and require little to no tinkering after initial placement. Boluses of medication always carry risks, inherent with initial placement. You have to watch the vital signs and FHTs very closely afterward, cause you will often see hypotension and resulting FHTs decels. Smaller, continous doses are much safer.

Continuous infusion plus educated use of PCEA is the way to go, from where I stand.

I was kidding . . . I've always thought "walking epidurals" or continuous infusions were the way to go. Our CRNA lives about 10 minutes from the hospital and that can be a lifetime for a woman in pain.

I was shocked when I had my son 5 years ago - my ob said I could have my epidural and the CRNA walked into the room 60 second later . . . too cool.

steph

[SierraN]

We "pass the responsibility" because it's not within our scope of practice to manage epidurals. That's why CRNAs and MDs have much more schooling and get paid a lot more - because they have a greater responsibility. If I'm going to take on the responsibility that rightfully belongs to the MD, then I darn well want his paycheck, as well.

Hi - where can I find the info about what's in our scope of practice. I'm an Alabama nurse and am having a hard time finding where it says in our Nurse Practice Act that we can't turn down the epidural pump setting. At our hospital we are often instructed by the MD to turn the epidural down because the patient is to numb to push. Sometimes we have to turn the pump off completely they're still numb after two hours! (But that's an entire other story...)

Edit - nevermind - i just found our (Alabama's) nurse practice act on line - we are allowed to adjust the pumps settings and change out the bags - just not give a bolus.