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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?
IMO, the problem here is the method of getting drugs to the pt. In most hospitals in the U.S., and I suspect, elsewhere, the drug is delivered to the nurses' station prepackaged by the pharmacy. The nurse checks what the pharmacy sent against the order, if s/he is not familiar w/that drug, hopefully looks it up, and if all is in order, gives the med to the pt.
That is not to say that the pharmacy doesn't make mistakes. That is why the nurse needs to know the drugs, doses, side effects, etc. But the nurse doesn't dispense the medication.
If a med error is made, most hospitals have a "no-fault" system in place to look @ where and how the error occured, not who's fault it is. In the case described by the OP, it seems to me (w/o knowing every detail) that the problem was not having the correct strength dose available--as well as misreading the decimal point (not the comma). 5 mg should not be written as 5.0 but just 5--the American accreditation board for hospitals (JACCHO) made that recommendation to decrease errors such as the one in this scenario.
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 correctedThis 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.
Great Dane,
First, you misunderstood stn2003. Please reread what was written.
Second, while I may agree with some of what you said, please refrain from making over generalized comments that may be found offensive to us Americans. Implying that it is so "american" to speak of suing and courts really burnt me. While I'll agree that there are those who want to sue everyone for everything and attorneys who are bottom feeders, I am glad I actually live in a country where injured individuals have legal recourse, unlike most countries in the world. And I'm ECSTATIC to live in the United States where we have the BEST healthcare in the world.
The most common reason for coma and/or decreased level of consciousness is decreased oxygenation of the brain. It is reasonably certain that this occured in this instance. As a result a pulse oximetry reading should have been taken and Oxygen supplementation given stat if the reading from the same indicated.
Also, this lady may have been dehydrated. Concommitant with oxygenation, IV fluid resucitation may have been indicated.
From what I've read, although I may be incorrect, hospital nurses, in general, do not give the all of the treatments ordered simply because they do not have the time to complete the same. Also, it is common knowledge that hospital nurses do not do the assesments and interventions requisite for quality patient care. This because they simply do not have the time to do the same.
Because of the aforementioned, I and many other nurses avoid hospital nurses.
As per legal negligence in this case, it requires: 1. Duty 2. Breech of duty (What a reasonable nurse using ordinairy prudence would do under the same or similar circumstances) 3. Causation 4. Damages
I am a Registered Nurse and Certified Legal Assistant.
well it is american to sue for health care. we dont have universal health care. the only 1st world country to not have it. that should burn you more than the statement. i have been to many countries and beleive me no matter what your hear in the united states, we dont have the best health care. our system is about money. unless big companies lose some there are never any changes. i would rather take my chances with a system that is only trying to provide good care than a system trying to save a buck. its them "the companies" that are really at fault. short staffing, because of money, not getting the best med because of money. good part about america is not that we can sue its the fact that we have the power to change the system.Great Dane,First, you misunderstood stn2003. Please reread what was written.
Second, while I may agree with some of what you said, please refrain from making over generalized comments that may be found offensive to us Americans. Implying that it is so "american" to speak of suing and courts really burnt me. While I'll agree that there are those who want to sue everyone for everything and attorneys who are bottom feeders, I am glad I actually live in a country where injured individuals have legal recourse, unlike most countries in the world. And I'm ECSTATIC to live in the United States where we have the BEST healthcare in the world.
in this case is it the nurses fault, sure any question about the ordered dose should have been verified with the doc. but do we have that kind of time. should she get into trouble, no not IMO. no matter what the drug. it should be looked at to see if it was intentional and the nurse should be talked to about it aswell as a note made in a journal of some sort to note any patterns. if the patient had died yeah the hospital should pay up. but the nurse should just get a talking to as if she had given a double dose of ASA. if there is a patteren to giving wrong doses for that nurse she/he should have to explain those action before the board and risk losing their lic. big companies like to point the finger at those below themselves and hold them accountable. if the company was the only ones held accountable for whatever honest mistake their employees did than they might see to it that their employees have the best possible conditions inwhich to do there jobs. like enough time to call the doc if dose is in question, even if it is just advil. currently they can say the nurse should of done this or that but did they provide a environment to do that. an example; we should wash our hand before and after every patient we touch, right? well if you have 6 patients and covering for another 4 thats 10, not a bad assignment for the typical med/surg floor. by the book we should spend 3-5 minutes for each handwashing. your assessment should take about 10min, by the book. so thats 10pt X 3min X 2=1hr and 10pt X 10min=1.6hrs, so to see each pt for 10min it should take 2.5hrs. minmum. this not including giving meds or doing anythng for the pt. usually during this first 2.5 hours they not only expect us to do the assessments but write it down and make a care plan give whatever routine meds need to be given and assess the needs for any PRN meds, go through the procedure of getting narcs if needed plus lots more tranfers DC's new addmits going for a CT ect. ect... and expect it all to be done with in the same time only provided to see each pt for 10min. now of course criminal acts would be in a different ball park but, that is for the athorities to determine if it was criminal or not. we need the time do things right, thats were the problem lies and issues like this really come from.
Great Dane,First, you misunderstood stn2003. Please reread what was written.
Second, while I may agree with some of what you said, please refrain from making over generalized comments that may be found offensive to us Americans. Implying that it is so "american" to speak of suing and courts really burnt me. While I'll agree that there are those who want to sue everyone for everything and attorneys who are bottom feeders, I am glad I actually live in a country where injured individuals have legal recourse, unlike most countries in the world. And I'm ECSTATIC to live in the United States where we have the BEST healthcare in the world.
I agree. :yeahthat: Well said. My first response was to insult Great Dane back. But I figured it wasn't a good idea to stoop to that level. Great Dane, sorry you hate Americans so much singling us out here on this International website. The statement irritated me as well. So quick to tongue lash an American when the entry was misread.
WOW - I hate americans all of a sudden, when did I say that?...
Some things might have been lost in translation or it came out wrong, but I think it is a bit rediculus to suggest that I hate americans. I'm pretty shure I never said that.
The "so american" was just a sarcastic joke, because you always hear people talk about sueing each other. We have courts here too and offcourse people should have rights and some DO rightfully sue the hospitals. Nothing bad was ment by it. I guess you would have something similar for "That is so typically European" when every yes/no question is answered with a "Maybe, but only if..." - I mean if you look at politics.
You get all the medicine pre packed? We have all the different types of medicine on the shelfs in a medicine-room, we get the list for each patient and pick it from all the different packs it comes in - don't know if there is an english phrase for that, but nobody does the job of packing it for us. If that is a good idea or not, is hard to say, but there has been some debate if we should do that or not. Most nurses don't like looking at 4 white pills in a pre-packed bag, not knowing if it is the right 4 white pills and then administering them to the patient.
As for the procedure, the nurse DID look it up because she didn't know the medicine, but she somehow got it wrong, dont ask how, she propably saw 25 mg as 2,5 mg or something.
Had any less experienced nurse been looking after my pt today, I wonder what would have happened. The doctor clearly wrote "loading dose of Digoxin 500mg stat", we have many new nurses on our unit who don't even know what antiemetics are! I walked to the doctor and said "I think you may have made a mistake", she changed it, no probs. But just think.......
>>The "so american" was just a sarcastic joke
Trust me when I say this is no big deal. People take the wrong meaning on message boards all the time.
Written text, especially on the Internet, doesn't convey sarcasm, irony, or lightheartedness very well. That's why we have smiley faces. :uhoh21:
Pel
The prepackaged meds are called "unit dosing", and they are labeled, every little one of them. In NICU, we get liquids drawn up in a syringe, again labeled as to what it is, and who's getting it--but we still check to see that they sent us the right drug and the right dose etc. All this is done in the Pharmacy Department by Registered Pharmacists.
The prepackaged meds are called "unit dosing", and they are labeled, every little one of them. In NICU, we get liquids drawn up in a syringe, again labeled as to what it is, and who's getting it--but we still check to see that they sent us the right drug and the right dose etc. All this is done in the Pharmacy Department by Registered Pharmacists.
and yes, you still have to be careful.
we've received (too often) meds from pharmacy with the wrong directions.
we finally ended up changing pharmacies but still....very scary.
leslie
Our pharmacy is our hospital's pharmacy. And I have discovered mistakes. But I still think it's safer than to be in a med room w/all these stock drugs you have to "pour", as we used to say, the meds for all your pts from a larger vial or bottle of pills or liquids. As a student a zillion yrs ago, that's what we did--w/people milling around the nurses station, asking you questions, interrupting you. I'm fairly sure we made mistakes.
My point is that, rather than blaming an individual (usually the nurse), if the hospital tries to troubleshoot the method of giving meds, and works to make it safer, that is a much better process. Everyone learns, noone is the scapegoat, and the pts get better care.
SFCardiacRN
762 Posts
If you follow the 5 rights of medication administration and look up dosages on medications you are not familiar with (esp. when new) you greatly reduce the chances of error.