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 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...
I most definitely agree with you. I was just using a flippant example. :)
You're not missing anything. I change the scale to show them that they don't have a waveform because they don't have a BP but when you change the scale....they have a waveform.
In the various places that I work, we need some SERIOUS hemodynamic/invasive monitoring education on square wave. It seems like everybody just looks at the waveform and says "oh, it's not good. We'll just go by the cuff instead."
I wasn't looking for kudos, I am sorry if that came off in the tone. I have almost made large errors myself, and was just hoping someone could maybe see that any of us can make mistakes. The superstar RN's with 20 years experience to the new graduate with none.
I was an LVN three years prior, and I can tell you, the fear of making a mistake that kills a patient is what helps me, but I know that every day, especially an insane day on a floor can make you miss something big. We are all prone to doing it, bedside reports are not done everywhere, and I think they should be for reasons such as this, two sets of eyes are better than one. As the one person stated about teamwork, I find that infinitely important.
I grabbed the other RN because I knew nothing about the patient yet, I had yet to receive report. I set her blood pressure in stat mode, it was hanging in the 80 systolic, she seemed stable and because the line was marked levophed and the pump was set to levophed but had a zithromax bag hanging, I went ahead and ordered the drip stat. If the drip ended up not being needed, fine, but I would rather have it when I grabbed the RN, then not have it. Can you tell me what I should have done differently?
I also grabbed her because I know she would rather have me tell her, than hear about it in an incident report, she actually went ahead with the nurse assistant manager and filled it out together. I was trying to be as respectful as possible, because some day that will most likely be me. She would rather self-report, than have me report it, that's why I grabbed her.
We are supposed to do mandatory bedside report, but no one does. It has been covered multiple times at my work, everyone is aware, I am sure the reasons vary between the nursing staff. But your right, I should attempt to be more proactive at my work, as we all should.
The RN stated the zithromax had been hanging in place of levophed when she came on shift, as she had never changed the bag. That was the information I received from her.
Different incident with a different patient:
I also recently mixed the wrong medication myself. I had to hang Levophed and because the patient had not received it yet, it is much quicker to mix, versus waiting for pharmacy, I grab the vials out of the omnicell. I pulled out the med with syringes. Grabbed another nurse to check with me, she just glanced, said "ok" and walked away. I then looked at the vials again, as I've barely ever mixed levophed, and realized the wrong medication had been in the omnicell. I had the drip already to go, was getting ready to spike the line, and that awful horrible feeling of almost doom hit. It was a medication I had never heard of, but I believe the dose was probably a lethal one had I actually hung the bag.
The errors here? I didn't check the medication that came out of the omnicell, yes it was in the wrong container, but that's my job to check and ensure it is correct. I overlooked it.
My second check with another RN was not really done, I should have grabbed her to look at the vials. Unfortunately this patient was a very unstable one, and needed the levophed stat, systolic was in the 60's, and that I believe made me overlook things such as the right dose. I hope that it continues to haunt me.
So yes, I know what it's like to almost make an error, I was just so grateful I caught it before harm was done. Maybe that incident is what made me feel more diligent lately in double checking. Perhaps I should have just told or started with the second incident.
There are no pedestals, we are all human, that's why teamwork, as the other nurse said is so important.
Always check iv drugs which have been made up in Pharmacy correctly I have picked up errors with drugs sent up from there.
Ab's which were unbroken and connected to bags of saline-you know which ones I mean the ones where you break the connection and mix the saline into a vial of medication then squeeze it back into the bag of fluid and shake. Well pt ordered certain dose the sticky on the front of the bag states pt name, mr number, drug name and dose etc. Well the sticky corresponded with the mar, dr's order etc but when I checked the vial it was a completly different dose plus on another occasion a different medication than was on the sticky on the bag!
Huge med errors!!!
Plus they send up 24-48hours supply and when we checked the whole batch was wrong including the one on the IV pole which had been given 4 hours early!!!
other RN's said they never check the vial!!!! Only the sticky and the saline!
Thanks for posting your experience, Nicki. It's a good reminder for all of us!
I'm going to step up high on my soapbox now and point out how this med error was not, and probably would not be caught by expensive, high-tech bar coding or other "fixes" that our administrators love to promote to the general public.
An excellent example of how short-cuts in basic nursing school safety procedures created a dangerous situation that high-tech couldn't find or fix.
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.)
I think you have made some excellent suggestions of how to manage a situation where drug errors occur!
I wasn't looking for kudos, I am sorry if that came off in the tone. I have almost made large errors myself, and was just hoping someone could maybe see that any of us can make mistakes. The superstar RN's with 20 years experience to the new graduate with none.
I was an LVN three years prior, and I can tell you, the fear of making a mistake that kills a patient is what helps me, but I know that every day, especially an insane day on a floor can make you miss something big. We are all prone to doing it, bedside reports are not done everywhere, and I think they should be for reasons such as this, two sets of eyes are better than one. As the one person stated about teamwork, I find that infinitely important.
I grabbed the other RN because I knew nothing about the patient yet, I had yet to receive report. I set her blood pressure in stat mode, it was hanging in the 80 systolic, she seemed stable and because the line was marked levophed and the pump was set to levophed but had a zithromax bag hanging, I went ahead and ordered the drip stat. If the drip ended up not being needed, fine, but I would rather have it when I grabbed the RN, then not have it. Can you tell me what I should have done differently?
I also grabbed her because I know she would rather have me tell her, than hear about it in an incident report, she actually went ahead with the nurse assistant manager and filled it out together. I was trying to be as respectful as possible, because some day that will most likely be me. She would rather self-report, than have me report it, that's why I grabbed her.
We are supposed to do mandatory bedside report, but no one does. It has been covered multiple times at my work, everyone is aware, I am sure the reasons vary between the nursing staff. But your right, I should attempt to be more proactive at my work, as we all should.
The RN stated the zithromax had been hanging in place of levophed when she came on shift, as she had never changed the bag. That was the information I received from her.
Different incident with a different patient:
I also recently mixed the wrong medication myself. I had to hang Levophed and because the patient had not received it yet, it is much quicker to mix, versus waiting for pharmacy, I grab the vials out of the omnicell. I pulled out the med with syringes. Grabbed another nurse to check with me, she just glanced, said "ok" and walked away. I then looked at the vials again, as I've barely ever mixed levophed, and realized the wrong medication had been in the omnicell. I had the drip already to go, was getting ready to spike the line, and that awful horrible feeling of almost doom hit. It was a medication I had never heard of, but I believe the dose was probably a lethal one had I actually hung the bag.
The errors here? I didn't check the medication that came out of the omnicell, yes it was in the wrong container, but that's my job to check and ensure it is correct. I overlooked it.
My second check with another RN was not really done, I should have grabbed her to look at the vials. Unfortunately this patient was a very unstable one, and needed the levophed stat, systolic was in the 60's, and that I believe made me overlook things such as the right dose. I hope that it continues to haunt me.
So yes, I know what it's like to almost make an error, I was just so grateful I caught it before harm was done. Maybe that incident is what made me feel more diligent lately in double checking. Perhaps I should have just told or started with the second incident.
There are no pedestals, we are all human, that's why teamwork, as the other nurse said is so important.
I think you managed the situation well and we can all learn from help and advice recieved on these boards!
I think it is human nature to be proud of oneself when we help to avoid error or we make a good decison regarding care.
When I make mistakes I want to be the one to know, I want to be able to correct it. Do not ever be afraid to approach anybody when errors have been observed.
I believe we should all practice reflection formally, and we can look back and learn!
You're not missing anything. I change the scale to show them that they don't have a waveform because they don't have a BP but when you change the scale....they have a waveform.
In the various places that I work, we need some SERIOUS hemodynamic/invasive monitoring education on square wave. It seems like everybody just looks at the waveform and says "oh, it's not good. We'll just go by the cuff instead."
You stated that some serious education was needed regarding line management. Now, I don't know in what capacity you are working (you mentioned working at more than one facility) so I'm not sure if you are staff at one place, agency at others, etc (and being agency may not put you in a position to do what I"m about to suggest) but I challenge YOU to put some educational materials together and offer to present them to staff. AACN has great references, you can use them as a jumping off point...and it takes almost nothing to throw a power point together. DO IT!
I never understand why nurses are so afraid of offering to educate other nurses. We all can't be the "go to person" for every aspect of critical care...I happen to LOVE hemodynamics and device management...and those are areas I offer to precept and teach in. Tying in teaching regarding meds and how they affect hemodynamics...well, I'm sitting here drooling at the thought! LOL Just an area I never, every tire of. I have a friend who loves CRRT. This guy knows the ins and outs of every machine our facility uses....I enjoy CRRT and the way it affects hemodynamics but if I"ve got a question, I go to Steve. He's definintely the "go to guy". Take the bull by the horns and get in there....do some inservices. Your standard of care for you unit can only improve and you may find a new aspect of nursing you love!
meandragonbrett
2,438 Posts
I most definitely agree with you. I was just using a flippant example. :)