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?
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.
I'm not a nurse. I'm a CNA and I work with lots of nurses and people are not always so kind to them. Nurses really get blamed for a lot of things even if it's not their fault. I always wonder why people are so hard on the nurses. Don't get discouraged from hearing about stuff like that because you would probably be an excellent nurse. Just because these things may happen to other people don't feel it will happen to you. I don't know you but I bet you will make a wonderful nurse. :) :balloons:
Over here (lordy, I hope....) if the med is pre-packaged wrong, then the manufacturer is to blame. You can usually identify if a pill is wrong or not if you've given it before. I have never come across this problem. All the pills in my hospital are single pre-packaged and in a computerized drawer system. It IS possible to pull out more than is needed and possibly overdose or underdose. The way around this is to always always check the meds againt the computer. We have a separate computer where we do all our charting. I'm sure that there are mistakes that this system can't prevent, nothing is failsafe.
IVF meds are mixed in our pharmacy and some come in vials that we attach a NS bag to, unless it's pre-packaged in a solution already.
There's a lot of trusting going on over here....if a medication is mixed or packaged wrong, HOPEFULLY the nurse isn't held accountable.
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.
Actually, I've never said anything like that, especially not typed up somewhere where it's hard to interpret if it was a joke or not. No problem. I'm not upset anymore...since you say it was a joke.
I wouldn't feel comfortable if I had to give some medication, where I didn't know if it was the right pill or not. Even though mistakes do happen, I would prefer if it was me who poured up the medication.
We do everything our selves, we prour up the pills, pull it up in suringes, mix the IV fluids if they come as a powder or if it has to be mixed with NaCl or something.
Some have talked about making it all computerised so it is a machine who pours up the medicine, because computeres are more relyable.
Offcourse the nurse should not be held accountable for a mistake made by the pharmacist. The correct dosis for growenups is usually 1-3 pills, so if you get a bag with 30 pills, or a suringe with 50 ml for IM injections, then there is clearly something wrong.
I once had a drugg addict who had to get 300 ml of Metadon in the morning,(100 ml can be lathal if you are not used to it) that is 1/3 of a bottle or 2 whole cups, like the ones you drink water from, usually it is 1 or 2 in a small glass, the same as you drink tequila shots from. Offcourse we were a little suspicious and we called a doctor, but it was right, he was just a serious addict - but I think it is because he tricked the doctor, it should just take the craving, not give you a rush, and it is a very small dosis. max 40 ml pr dosis I think it is, more than that has no effect on the craving, even though they often more than get that - but there is also a mental craving for the rush. It was someone who had worked with addicts for decades, who told me that. A nurse who had worked in the pharmacytical industry for a lot of years also told me that more than 75 mg of magnyl has no effect on preventing trombosis etc, but a lot of doctors dont know this and offcourse I would pour it if it said so.
I would prefer to pour it my self, but it does make your day a lot easier, and takes some of the work load off, if someone did it for you and you just had to tjeck it
Med errors happen and need to be delt with as soon as they are noticed or occur. The pt is our main concern, deal with that first..inform Dr....pharmacy, etc. Treat, observe whatever it takes.
Then figure out why it happened,usually it is a system problem. If this is a recuring problem with the same RN, there should be more education required for the RN.
I'm not a nurse. I'm a CNA and I work with lots of nurses and people are not always so kind to them. Nurses really get blamed for a lot of things even if it's not their fault. I always wonder why people are so hard on the nurses. Don't get discouraged from hearing about stuff like that because you would probably be an excellent nurse. Just because these things may happen to other people don't feel it will happen to you. I don't know you but I bet you will make a wonderful nurse. :) :balloons: 
all4schwa
524 Posts
it is the way of some to be quick to sue, that's why we are quick to CYA
the comma is a european thing...