Almost made 1st med error. Who's at fault?

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I had a patient yesterday and the doctor gave an order for Decadron. I checked the patient's allergies as noticed she had an allergy to Solu-Cortef (although the patient has successfully taken Solu-Medrol and prednisone in the past). Anyhoo, since both are corticosteroids, I started questioning the order. Called the pharmacy first, not much help, so called the MD. MD said a reaction was unlikely, but changed the order to Solu-Medrol IV.

So, the pharmacy sends up the med. They substituted methylprednisolone, no problem. So, I look in my drug guide which states to administer slowly and is compatible with NS. Prepare the syringe for IV push.

Come to find out, the patient's INT was occluded. She was African American and a hard stick, so it took 3 of us and about an hour until we could get a new INT started.

By this time, I notice that the medication had precipitated inside the syringe. So, I ask my preceptor about it, and she tells me to shake the syringe before administering. Hmmmm? So, I ask another nurse who takes a look and says something's not right.

So, we go back to the vial, and now notice that the vial says Not for IV use, for IM injection only. Turns out that the pharmacy sent methylprednisolone acetate instead of methylprednisolone sodium succinate.

Never having given Solu-medrol before, I didn't know what kind of vial it should come in, or that there were different forms of the drug. THANK GOD that the med precipitated which caused me to question the med. Had it not precipitated, I know that I would have pushed the med.

I have always double checked the med and dose, but never thought about reading the vial closely enough to notice the fine print. What could I have done differently? Of course, I will check this from now on, but I'm just freaked out about how close I came to making this error.

The charge nurse filed an incident report to hopefully bring light to the potential error. Does anyone happen to know what kind of reaction could have occurred? I'm almost scared to ask. :eek:

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Specializes in Cardiac Nursing, ICU.

Don't know but great catch!!!

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Specializes in Psychiatric, Med Surg, Onco.

Definately an OMG learning experience. No matter who initially made the error (pharmacy sending up wrong med...) you will suffer the consequences if the error continues and harms the patient. The pharmacists at my facility are understaffed and BUSY...aka...ALWAYS read your vials...if it is only for IM use, it is probably caustic to veins...you got lucky. Thank God you had the courage to continue to question it.

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Specializes in Med Surg, Ortho.

I'm a new nurse as well. I want to thank you for sharing this experience. I love this site and love learning new things from you all.

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Specializes in Operating Room Nursing.

I have no idea what the reaction would have been, thanks to you it DIDN'T happen, well done for questioning the order :)

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.......................She was African American and a hard stick, so it took 3 of us and about an hour until we could get a new INT started.

what does the race have to do with it......am I missing something??? I have plenty of non African American patients who are hard sticks. :confused:

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Specializes in ICU/CCU, Home Health/Hospice, Cath Lab,.
what does the race have to do with it......am I missing something??? I have plenty of non African American patients who are hard sticks. :confused:

Not really race but skin color. The darker the skin the harder it is to pick up the blue of veins. If you take someone like me, somewhat overweight but rather pale- you can't feel a lot of my veins, but you can see the blue of the them. It doesn't necessarily make them a harder stick just harder to find the vein in the first place.

Hope this helps

Pat

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Specializes in being a Credible Source.

I have always double checked the med and dose, but never thought about reading the vial closely enough to notice the fine print. What could I have done differently?

I think you know the answer to your question -- read the vials.

I'm very thankful for you and your patient that (a) the delay allowed the precipitation to take place, (b) that you noticed it, and © that you didn't just take the "shake it up" advice but rather investigated and found the issue.

Give yourself a quick finger-pointing for not having read the label and then a big, whopping pat-on-the-back for not following your preceptor's direction but instead investigating and discovering the screw up.

I don't know what might have happened but it's possible that you saved your patient's life.

Good for you.

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Specializes in being a Credible Source.

I'm curious, which drug guide did you check?

I just looked up methylprednisolone in Mosby's Drug Guide for Nurses by Linda Skidmore-Roth and found the following items which might have provided some warning to you:

Under "Dosage and routes" it says,

Adult:... IM 10–80 mg (acetate); IM/IV 10–250 mg (succinate)...
.

and

Available forms: ... inj 20, 40, 80 mg/ml acetate; inj 40, 125, 500, 1000, 2000 mg/vial succinate
.

and under "Implementation"

IV Route: Give IV, use only sodium phosphate product; give >1 min
.

This last one is a little disconcerting only because sodium phosphate is not one of the ones listed under "dosages/routes".

In any event, if you'd read those statements it might have caused you to double check the formulation that you had in your hand. Out of curiosity, what was the prescribed dose?

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what does the race have to do with it......am I missing something??? I have plenty of non African American patients who are hard sticks. :confused:

Well, gee....have we become so PC that we can't simply mention a person's race without making a federal case out of it??

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Well, gee....have we become so PC that we can't simply mention a person's race without making a federal case out of it??

gee tangolima,

I'm sorry you felt that way....i really was not making a federal case out of my query....I just wondered what your statement meant and thankfully Patwil73 an experienced nurse clarified it for me.

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Wow, glad there was no harm. Thanks for posting as we also use this med a lot.

Live and learn -- sometimes I think God is standing over us many times making things happen to cause these "near misses," but to help us to learn.

Always humbling, isn't it? :)

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