Big med error and communication breakdown

[Zippy83]

The patient does not seem to have had any serious symptoms or adverse effects related to the error, thankfully.

However, both adult children are MDs and they have already called to formally complain to the hospital that referred us, the pharmacy, and have threatened to sue.

I’ll try to sum it up the best I can without being too specific:

A patient was admitted by RN, on a cadd pump medication that is supposed to be continuous. It’s not an opioid or pain medication of any kind. We have several patients on this exact medication delivered by CADD pump, and medication and pump are provided by the same pharmacy we always work with.

I didn’t have a complete and correct report on the time the last cartridge was place or the amount of reserve volume, and I didn’t get to the house until 2 hours after the bag emptied.

The family was questioning me like it was a deposition. I made a great effort not to shift blame or admit to any specific error personally, while also being compassionate and professional. I mainly deferred to the agency and my supervisor, but made sure not to come off as hostile.

This is very unlike me, I’m usually so anal retentive I sometimes irritate patients or other nurses about what I won’t do or change without an MD order, when some nurses have become complacent or casual. But this time I feel like I took a casual report and it bit me in the bottom. Luckily the patient is ok. I feel terrible. This is my first big mistake in 7 years as a nurse. I will have to wait and see what comes of it.

[JKL33]

So what was the error? That you didn't have accurate information about when the bag would be empty and therefore there were two hours' of time where no medication was being received? Were you supposed to have independently ascertained this information?

[Zippy83]

Yes the med error was 2 hours with no medication, it is supposed to be continuous with no breaks except to change the cartridge.

I gave an arrival window, then ended up needing to push it back by an hour and called ahead to let them know and they said ok, I guess the wife also was not aware of the reserve volume at that point. But the kicker is that even if I had arrived in my original time estimate, the bag would have already been empty for up to an hour, so the error was going to happen either way. The RN who did the SOC ok’d my arrival window and did not say “No, you need to come earlier, I came at X time and this bag has almost no leeway, you need to arrive no later than X”. Instead, when I gave my arrival window, I was told that would be fine because the family would be home all day.

So I was not given enough info, but I also didn’t make sure to ask. Usually this specific med from this pharmacy has nearly 8 hours of reserve so that the bag can be changed at any time during normal hours (so if it needs to be changed every 72 hours it really just needs to be every 3 days, etc), I was not informed that this case was different, but I didn’t independently verify it either.

[JKL33]

I would encourage you to not go overboard entertaining others' hysterics about it. It is a lesson learned for everyone involved.

You are properly acknowledging that in the future you will get more info to verify correct timing of visit. If you are being singled out by others with punishments, etc., I personally would not tolerate that - but that's just me. The world isn't perfect. Aiming for prudence and excellent care is a worthy thing and can be said to be our duty, but the day-to-day burden of individual responsibility for perfection is no longer something I accept.

TBH I'm pretty sure I wouldn't want this case. It sounds like it involves ridiculosity from two people who should know better.

[Zippy83]

Thanks, it’s nice to get some perspective. What rattled me was the son, he was extremely aggressive and threatening.

The other nurse acknowledged that she didn’t even think to tell me about the reserve when I gave my arrival time, she optimistically imagined I’d arrive at the beginning of the window. So I’m not being singled out necessarily.

The main issue is that this is a critical med, that two hour window could have potentially caused real harm. It it didn’t, so we will move on and learn from it.

I was taken off the case, so luckily I don’t have to return.

[JKL33]

4 minutes ago, Zippy83 said:

What rattled me was the son, he was extremely aggressive and threatening.

I'm sorry that happened. No need to go into detail about his exact reactions but just know that you should have a mindset of not tolerating various permutations of aggression and threatening behavior (and an plan for when you encounter it).

It's good that you are off the case. Since no one was hurt and it sounds like you have learned what you can from the scenario, it will be very good if you move on emotionally now. Others' specific reactions are generally about them and are not what defines someone else's prudence, integrity or professionalism, etc.

Take care ~

[traumaRUs, MSN, APRN]

CADD pumps beep and beep and beep so why didn't the MD adults call someone?

[Zippy83]

So the patient was at home with his wife, but the wife did not call anyone or do anything about the machine beeping. Also, it would have been beeping at the times that I called her to give her my new ETA. So any of this information would’ve been helpful at the time.

Apparently one of the children called to check up on them and see if the nurse had come, and they told her that I was going to be there in another 30 minutes, and that’s when she realized because she had been there during the last bag change that it would have run out. So then she went to the house and it was beeping and while she was in the middle of scolding me, she was also telling her mom that if it beeps if they need to call someone.

It all turned out fine essentially. The family allowed our agency to continue care but I am off the case so I don’t have to deal with them. And I got another patient assigned to me recently with a similar cadd pump different medication, and this time I got full report. The time of the last bag change, the infusion rate, volume of the bag, so I was able to schedule my visits ahead of the expected time that it would run out. Lessons learned.

[berube]

Was the bag REALLY empty or looked empty cuz CADD beeps when empty!

[Zippy83]

1 hour ago, berube said:

Was the bag REALLY empty or looked empty cuz CADD beeps when empty!

It had been beeping but the patient and wife ignored it and didn’t tell anyone or take a look at the pump, even when I called to give a new ETA. ??‍♀️

[ModelMom, ASN, BSN, MSN, RN]

JKL33 is ABSOLUTELY right! I'm sorry you were a victim of such inappropriate behavior, but grateful that you know how to handle such a situation in the future. None of us are perfect, which is why we have insurance. So, keep that in mind and move forward in your growth, as to not enable this situation to be a positivity sponge. Good luck with everything :)!

Remember, We RN this together

Trischana