chemo error!!!

[me5115]

The worse thing that could happen, happened today!!!

The nurse I was working with gave a pt the wrong chemo. She hung another pts Topotecan instead of mesna... It makes me sick thinging about it. I have worked here for almost 2 years and I always do my double checks. The senior nurses however dont always.

I had my gloves on ready to hang it and she had it in her hand ready. I said oh your hanging that. About 20 min I went to check on the pt and it was not hanging. I asked the other nurse about it and she said I didnt hang it. So we went to the counter and it was not there. But of course the bag of mesna was. I knew right then what she did. She ran to the other pt to shut off the topotecan. He already got most of it. So she left crying to tell the nurse manager.

Later on, The manager asked to speak with me, I told him what I knew. He said well once you do your double checks you dont sit the chemo down, you hang it right then. Meaning she had me double check it. I said I didnt check it with her, unless the LPN did. I know she was covering herself. But half of the nurses dont follow protocol. It was bound to happen.

We are so crazy busy back there, with a million interuptions and not enough room.

On the bright side, maybe will get a better system set up.

Anyone else have similiar experiences and whats your protocol for hanging chemo. Also if I see a nurse not doing the checks , is it my responcibility to say something. The nurses I work with have been doing it for 10to 20 yrs. Its kinda a difficult situation. Of course pt safety should be before stepping on someones toes.

[amandaland]

In a busy office , it is eassy for mistakes to happen. I am the only nurse in my office, and do not have another nurse to do 2nd checks with. I ask the pt their name (even though i know them) and i show them their name on the bag and ask them if that is their name, and i tell them which medication i am giving. A coworker of mine at another office had a similar incident where she drew up the pts aranesp, got called to the phone, and gave the injection to another nurse to give. she told her what it was and for which pt, and that nurse gave it to the pt push via port. She stated, "she thought it was his velcade."

[iluvivt, BSN, RN]

Check it at the pts bedside and use the six rights The nurse skipped those We also co-sign the MAR and then witness the hang or push, Yes it takes time but it is so worth it. Many pts have died because of wrong route and wrong dose chemo mistakes

[me5115]

People make mistakes and thats why the checks are in place. But they are only as good as the poeple who use them.

What happened with the aranesp thing, was the pt ok?

My biggest fear is that the topotecan will drop the pts already low platelet count and his next chemo will be deferred. He is a young testicular with brain and lung mets, on his second round of chemo. He responded the first round, but relapsed quickly. It is sooooo important he gets the chemo on time. He already had to be decreased to 50% dose because of the platelets.

Thanks again

[nursemary9, BSN, RN]

Hi

I work in an In-Pt. Hem/Onc Unit.

We have to check our chemo with another Nurse. Before we do anything

we have to do a TIME-OUT;2 of us need to sign. I don't know about other shifts, but on nights, we do actually do them all the time. I don't know anyone who does not do them--even us oldtimers do them;