Caught a big med error!

SmilingBluEyes · Jun 4, 2010

GOOD JOB~ that is what it's all about. Trust me, if you spend a considerable amount of time on the job, you will make some kind of mistake, or come near it. And hopefully, you or someone equally vigilant, will catch it before it happens or does harm.

CaLLaCoDe, BSN, RN · Jun 4, 2010

Nice work! Hats off to your observing this! Curious why it isn't mandatory for two RNs to check off a pressor when hanging it? I mean we have to do it when hanging chemo, why not with lethal drugs like leave's em dead (Levophed)?

CNL2B · Jun 4, 2010

In my ICU, it is not required to re-check your drips with a second person if you are just hanging a new bag -- it's required at shift change and when you get handoff from the PACU/OR or another ward. But yep, that was a biggie -- luckily it was caught quickly.

Along the same lines, a nurse I work with was covering a lunch for another nurse that had a post-op CABG (about 3-4 hours out of the OR.) I noticed that the B/P was beeping low (70/40s) at the central monitors and alerted her to it and told her a pump was going off in the room as well (she wasn't in the room, obviously.) She told me the art line was positional. I go into the room to fix the pump, and the neo was out. Ah hah -- it was a perfectly functional art line after all. Luckily the nurse had re-ordered the neo prior to her leaving for lunch and there was an extra bag at the bedside, so it was easily remedied. But, goes to show -- you can never get too lax in the ICU when you have drips hanging.

Glad your patient was ok.

cb_rn · Jun 5, 2010

Reminds me of the time one of the excellent nurses on the unit accidently hung a second bag of heparin instead of milrinone. Yep. 2 hep drips, no milrinone running in the PICC. Nobody did the 2 nurse check at shift change because the off going nurse was super nurse (seriously, just an all star on the floor) so it wasn't caught until hours into the night shift. I was brand new on the floor and soooo glad it wasn't me taking care of that patient. After that, nobody would be caught dead not checking a drip at shift change. So the patient was fine and it ended up being an excellent learning experience for eveyone on the unit even though it caused a few heart palpitations in staff that night.

dthomasa · Jun 5, 2010

:yeah:Hoo-Ray,,,thats why its called team work,,,,It takes a village of Nurses to take care of one patient.

Katie5 · Jun 5, 2010

:yeah:Hoo-Ray,,,thats why its called team work,,,,It takes a village of Nurses to take care of one patient.

Nice quote. I love it.:)

simboka · Jun 5, 2010

That's the point of bedside report.

highlandlass1592, BSN, RN · Jun 5, 2010

I went to work the other day, Cardiac ICU. And most of the nurses at my work do not do a bedside report. I often will go check the room just to see what state my patient is in, what drips they are on, etc. I saw that my pt's BP was 80 systolic, curious I looked at the lines, saw Levophed was hanging, and checked the bag...which read Azithromycin. Realized that there was no vasopressor hanging on this ladies BP. So even though I had not received report yet, I hit the hold button, and ordered a bag of levophed stat, grabbed the RN while she was still giving report and showed it to her.
This is an excellent nurse, often works charge and resource, has been around for 10 years and it happened to her. Same with the day nurse who is assumed to have hung the medication. And I, the nurse with a year experience, caught it.
It was reported and everything is going through proper commands.
Just wanted to share, hopefully it will help someone else from making the mistake. I often check all my bags multiple times during a shift, see how I'm doing on fluids and plan to reorder new bags early so I don't run out. But it can happen to anyone.

I had to smile when I read your post. It sounded like you were a newer nurse when I started reading it and bingo! There it was..."I, the nurse with the lesser experience, caught an error that got by nurses who are supposed to be so much more experienced, blah..blah..blah". In fact, I remember making similar comments when I was a young nurse in the ICU's. Your comments really had me experiencing some interesting emotions.

You see, when I was a young nurse...I really thought I was infallible. I was going to rock the ICU cause I was diligent, kept checking things repeatedly throughout my shift, would NEVER dream of leaving a fellow nurse with the mess I left...yadda, yadda, yadda. The list goes on....throw in any adjective that could describe how great I was and I believed it about myself. But you want to know something? All that checking, all that repeatedly reading of orders wasn't due to diligence..it was due to fear. Fear of killing someone, fear of missing something that would make the difference between life and death for one of my patients. I DIDN'T know it all....and thank God I finally realized that.

You see, when you started out by saying things like "most nurses at my work don't do a bedside report...I often will go check the room and....check my drips" then you found an error had been made. You stated your patient's systolic bp was in the 80's....You jumped to it and ordered that drip stat and got that nurse who was trying to give you report in there so you could be sure to show her her mistake. Then to add things to the mix you had to go and state how many years experience this other nurse had and that she frequently works charge and is a resource for others..you then proceeded to mention that it was not caught by the other dayshift nurse who also had more experience than you as well. You then tried to wrap things up by saying you posted as a warning to others...so this wouldn't happen to another patient.

You know what I think? You posted all of this to get some Kudos...and some members here have definitely given them to you. I just can't find it in my heart to do the same. I won't give you kudos for your post because to me, it comes across with a superior attitude on your part..."look how much better I am than these experienced nurses ....I would never do this".

Let's analyze the situation for a moment..if your ICU is like one of the oh, say 18 I've worked in thru the years, people usually help each other out. How do you actually know who hung that antibiotic as a drip and made the med error? Were you there to witness it? No?... then you can't be sure. All you could have put in an incident report is that when you assumed care for your patient, you found an incorrect med hanging. Was something happening during the day that may have contributed to this situation? I can think of hundreds of reasons that GOOD, STRONG and EXPERIENCED nurses make mistakes every day....as well as INEXPERIENCED, YOUNGER nurses as well. You honestly can't state what happened unless that nurse you got report from told you so specifically..which you didn't share with us. You then go on to pat yourself on the back again because while other nurses on your unit don't do bedside report, you go in there to "check things out". And let's talk about what you did when you did discover the error...you stopped the antibiotic then ordered the correct med. But you left your patient to go get that other nurse to show her the mistake...so you left your patient unattended to do this? And while we're on the topic, you seem to indicate that a systolic BP of 80 wasn't good for your patient...was it wise to leave that pt to go tell this nurse? Wouldn't it have been prudent to call a doc and figure out how long this pt had been off the pressor...maybe it didn't need to be restarted???? And let's face it, with some heart failure patients, a SBP of 80 is great...they may need off-loading to keep function as best as possible.

I will state there is a lot of information here that is missing...I don't know this pt's diagnosis, vent status, heart status, kidney function...etc. I don't have a clear picture of the overall status so I can't really state that your actions were right or wrong...I did float the questions above to share thoughts I had about the situation. There are a lot of unanswered questions here..but your desire to "share" to me, is, well suspect.

You know what? If you truly wanted to offer a warning to others regarding the fact we ALL make mistakes...you could have changed the entire tone of your post by doing it in third person. Not making it about what you had done but stating that this situation had happened in your unit and then shared what your unit had done to see that this never happened again. Hmm..that is missing from your post...the process improvement side. Did you sit down with your manager/supervisor, suggest this could be a case presentation for a nursing M&M? Did you propose a change in shift report, one to make it take place a the bedside to ensure these kinds of errors are caught? Did you propose a double check for drips initiated in emergent situations or when bags are changed??? What did YOU do other than post here? That truly reflects a situation where kudos would be given in my book....when a nurse realizes a process needs to change and instead of BLAMING a fellow nurse, helps come up with a solution to fix the situation.

You did what is expected of EVERY ICU nurse when they come on shift..it's the first lesson you learn in any orientation..you assessed your patient. But when you had the opportunity to throw a touchdown by finding a problem and trying to fix the process, you fumbled the ball and minimized coworkers and fellow nurses by trying to make yourself shine. And really, that's a shame...because, one day...YOU will be the one making a mistake....and hopefully, a coworker will help you out and not tear you down. Don't say you'll never make such a mistake..I guarantee you will. We ALL do. It's how we deal with the situation when we make that mistake that counts. Keep being diligent...keep being thorough...but try to build your coworkers up, not tear them down. We have residents and other docs around that do that well enough......we don't need to add anyone else to that group.

(I apologize for the length of this post to any who make it all the way through...this post just resonated with me, as you can see.)

meandragonbrett · Jun 5, 2010

She told me the art line was positional. I go into the room to fix the pump, and the neo was out. Ah hah -- it was a perfectly functional art line after all.

I think this has to be the *most* irritating thing I hear on a routine basis. Your aline is likely not positional as it was placed less than 3 hours ago. You're waveform is dampened? Do you even know what that means because you have an adequate sq wave. You have no waveform because you have no blood pressure and you need to change the scale. :yeah: :yeah: :yeah: :yeah:

highlandlass1592, BSN, RN · Jun 5, 2010

I think this has to be the *most* irritating thing I hear on a routine basis. Your aline is likely not positional as it was placed less than 3 hours ago. You're waveform is dampened? Do you even know what that means because you have an adequate sq wave. You have no waveform because you have no blood pressure and you need to change the scale. :yeah::yeah:

Interesting position to take..at some facilities, it is against policy to change the scale. It also brings up the point of: do some people need more education regarding how to properly manage arterial lines? Maybe the situation warrants a refresher for people having this issue.

I can't agree with your statement though regarding the timing of the line..I've had lines put in that dampened within an hour and quickly became positional...many different reasons but the most interesting one was a pt who began seizing...definitely moved the catheter and it never really did recover. Also, the patient population itself can have an affect: we deal with aortic dissections frequently and depending upon where the dissection is can affect the line as well. The key is really to do a thorough assessment of the pt and be very familiar with their history as well. You can never have too much info, in my book.

tri-rn · Jun 5, 2010

Sorry if this is a little bit of a hijack, but what good does changing the scale really do anyway? Other than being able to see the waveform more clearly? I had a pt once , low bp, no uop, etc etc...and the nurse I'm giving report to runs in and changes the scale like it fixed something. I mean, it doesn't change anything for the patient?? I don't really get it. I knew the line was good, good square wave and the waveform itself was ok just small. WHat am I missing?