Allmost killed a patient by medication

[Great Dane]

Here is an example - there must be LOTS of them, thinking of all the number of pills being administered, it is impressive that so few mistakes are made, acually.

An older lady patient, from another country who didn't speak the local language, had a massive apoplexia a year before and was paralysed on the left side of the body + blind on the left eye. She took lots of medication for the sympthoms from the apoplexia and 5mg x 3 Baclofen (spasmolyticum), was one of them. They are in 10 mg and 25 mg pills, but in this department they only had the 25 mg types

She came to the medical E.R. because they couldn't wake her up in the morning, and she fell asleep soon after - she had NIDDM but the had a normal bloodsugar when she came in. The son translated when she came in, in the afternoon.

The next day she had to be transfered to another department.

A nurse had to administrer 5 mg Baclofen she didn't know the medication and looked it up, took the 25 mg box and gave the patient 2 pills, thinking it was 2,5 mg. So it was 50 mg and not 5 mg she got, meaning 10 times the right dosis (she didn't get them in the evening). Intoxification signs are from being sedated, uncntious, coma to dead. The strength of most medication is made so 1-2 pills are the usual precriptioned dosis, so 2 pills didn't seem strange at all.

At noon the same nurse had to administer the patients medicantion angain, and saw that it was the wrong dosis. She ran to the patient saw that she could be awoken, but fell asleep soon after. She didn't speak the language, so she couldn't tell if the patient was talking clearly or hazy, the left eye didn¨t respond to light, because she was blind. The bloodpressure, puls, SO2, and temperature was OK, the breathing was very deep. Like she was just sleeping very tight. The doctor was called and he said that if the patient was going to die from it, then it would have happened allready, there is no antidot. So they had to check up on the respiration now and then, and mesure the bloodpressure, puls etc. every hour.

The head nurse was informed and the accident was repported and written in the medical and nursing journal so they knew when she got transfered to the other department

She had a good deep sleep most of the day and that is all.

Nothing serious happened and when the mistake was discovered everyone reacted "by the book" nobody tried to cover it up or anything. But had it been another type of medication, or had she not noticed her mistake when preparing the next dosis at noon, then the patient would have died

Should it have any consequenses for the nurse?

If it would, then some might be tempted not to repport such an accident, because when they discovered the mistake, the acted at once and just as they were tought to act.

But would a penalty in any form serve a purpuse? A punishment is a way of saying "don't do this, or bad things will happen to you" I don't think this particular nurse will EVER make a mistake like this again.

Would you ever be abel to go back to nursing after that?

[jen42]

Would you ever be able to go back to nursing after a medication error? I certainly hope so, since I and ever nurse I know has! Would you be able to go back if it was fatal? Well... that's a different story.

[stn2003, RN]

Nurses are only human, and we are all capable of making errors. Some medication errors are obviously more dangerous than others, but are errors nonetheless.

Do I think there should be consequences? Sure. Obviously, the nurse herself could be held liable in court by the pt./family if harm had occurred and the nurse was sued. Internally, the nurse could be required to take a remedial medication/administration course or have supervised med passes under which she triple checked her 5 rights of med administration with no errors for a period of time. If this was a problem that kept re-occurring with this nurse, despite remediation, she could be let go by that facility.

Do I think these things would keep a nurse from reporting an error? No. A big principle in nursing is ACCOUNTABILITY, owning up to actions and lack of action despite its goodness/badness.

I personally have not been in a med error situation as of yet, but I have not been nursing all that long. And no part of me will say it is not possible, because it is possible as we are all capable of error. That is why it is so important to know what you are giving, look it up if you don't know, go to your NM when in doubt, and follow the rights of med administration. I hope that I my own shame would not keep me from going back to nursing after an error, but I would have definately been accountable for my actions and taken steps to decrease the possibility of it ever happening again.

[wooh, BSN, RN]

Any nurse with integrity would learn from a mistake like that without formal punishment. And as you said, punishment breeds covering up which can lead to far worse consequences than the original med error. Not to mention, med errors are rarely a one person at fault sort of thing. It's a process that involves many things and people.

[Serenyd]

This is why nursing sucks. Bad hours, no holidays, no respect, and if you screw up, you kill or hurt somebody. I wish I had a job where if I put the decimal point in the wrong place all that happens is I screw up the books and have to fix it. But I choose nursing. Six weeks of half-a** orientation and then I get to go out and play with people's lives. And most of the time I just don't feel qualified. When I hear about stuff like this, it makes me want to quit altogether.

[LearningRN]

Hey Seren21. I hear you... In fact I've stopped working as a nurse. I'm a new grad with about 6 months of experience, and I quit. I couldn't handle the stress.

[bagladyrn, RN]

The punishments we put on ourselves - I'm sure this nurse will be thinking of this incident long after everyone else has put it behind. The emphasis of the organization should be on prevention: "What safeguards or procedures can we put in place to prevent this happening again?". This is where the emphasis should be in talking with the nurse involved, not in punitive measures.

[Great Dane]

stn2003 - you are so "american" talking about people getting sued and going to court. What you suggest, with someone breathing her down the neck is humiliating and surves no purpuse - over looking a comma doesn't call for that. It would make anyone want to cover for your self or fellow nurses, and then accidents or malpractice will never be corrected

This nurse has propably given a million pills before before she saw 25 as 2,5 or what ever happened

Personally I think it is a very big burden to put on a person to be in a room full of druggs, having to pick the rights one and the right dosis - and we all know how well doctors write - knowing that if we take the wrong one or in the wrong dosis, then people may die. Doing that potentially deadly "game" several times every day for years and decades, even though we all learn and know the druggs, it does take a lot of responsibility.

I don't think anyone who takes up nursing, takes that responsibility lightly.

If we punish nurses that hard, then they/we will just start to cover it up and then we will never correct the flaws in the procedures we have. Maybe the solution would be to electronical medical journals (they used the written on paper type) or improve the ones we have allready, maybe even to have a machine sorting the pills.

[jen42]

Ok... I just want to say to Seren21 and LearningRN, there *are* jobs outside a hospital where you get holidays off (and even weekends!) that are *much* lower stress. Thanks to the nursing shortage, you can work there as a newish grad without much experience.

[weetziebat]

Any nurse with integrity would learn from a mistake like that without formal punishment. And as you said, punishment breeds covering up which can lead to far worse consequences than the original med error.

My thoughts exactly. What could possibly be gained by punishing a nurse for an honest mistake? We are human, we make mistakes, no matter how hard we try not to, and being punished will only cause people to cover up their mistakes - and no one will learn from that.

We need to try to find ways to cut back on the possibility of others making the same mistake, not making nurses so paranoid about errors that they leave the profession. I'm sure this nurse has beat herself up worse than anyone else ever could.

[stn2003, RN]

Great Dane- notice that i said "could". a person could be sued. it could be suggested they take a refresher course. they might even have to have witnessed med passes for a time period, depending on the severity of the mistake/number of mistakes for that nurse personally. I did not say I was for these things, just that they could-and do at times- happen. There is a difference between punishment and remediation.

I agree that the personal guilt someone could feel after a mistake far outweighs anything that might be imposed on them. I have heard of nurses who have left the profession because of it : / It is a shame.

And because it is often true that there are things that contribute to med errors such as look-alike/sound-alike drugs, drugs available in numerous concentrations, misleading labeling etc., this is why it is so important to admit the error and bring it to the eyes of your supervisors/risk management team- so that this mistake can help prevent future ones like it.

[HappyJaxRN]

Accidents happen. It's unfortunate, but they happen. To err is human. It isn't to be taken lightly, but a nurse shouldn't loose his/her job unless it's a reoccurring problem, he/she has caused permanent disability, or death.