Adult female pt came to ER c/o severe abd pain. Was triaged for same in ER day before - left R/T long wait time. Hx CRF, currently doing PD @ home, after assessing her I asked another nurse to start her IV (I was pretty busy w/ other pt's) she put a 20g in L wrist. Before doc had seen her I sent blood (drawn by other RN when IV started) for lab/blood cx. Also sent PD drainage for cx.
After doc saw pt no other labs ordered. Pt given Demerol/Phenergan for pain, flushed w/ saline before & after and meds were diluted in 10cc to ease the burn.
Labs came back - pt has peritonitis. Holding her as admit - waiting on room. Throughout day several doses Demerol/Phenergan given in same fashion as above. @ 1600 when pushing Demerol/Phenregan pt stated it burned. I stopped, asked her if it burned @ insertion site. She said "no, it burns all the way up my arm, the same as before". I flushed w/ 10cc of saline before continuing w/ meds to make sure no infiltration, then again flushing after. Site was not swollen nor any change in color.
About 30 minutes later pt c/o pain at IV site. Swelling noted. Saline lock was removed, hand eleveted on two pillows and hot wet towels wrapped around hand. Re-check approx q 5 min each time re-apply new hot wet towel. Within 30 min hand started to swell, appeared like venous congestion. MD notified - charge nurse notified. I checked radial and ulnar pulses w/ vascular doppler and checked pulse oximetry on each finger (all was normal)also motor sensory was normal. Within approx 10 min MD in room and plastic surgeon consulted. Plastics doc shows up within about twenty minutes, by this time hand looks like crap - swollen blue/purple - loosing sensation, pulses still strong, motor still intact. Decision to take to OR for fasciotomy. I gave my manager full report within twenty minutes of pt going to OR.
Next day I was called to meeting w/ administrative legal people - risk management - me and my manager. It was deemed a "Centinel Event" and we had a "Root Cause Analysis Meeting". Although this meeting was supposedly to "figure out what went wrong and prevent it from ever happening again", they were asking me things like "what is your experience, how many hours did you work that day, how many shifts in a row was this for you, what other type of pt's did you have that day, how busy was the ER?". It was a little intimidating and they nor I could come up with anything I could've done to prevent this - however my charting was picked to pieces. I chart a significant amount more than most of our ER nurses, I even make some of them chart more before they report off to me. Am I at risk here because of too little charted? Everything in this posting IS CHARTED.
Although this was an unforseen event in my situation, I now am refusing to give phenergan IVP. None of our ER docs have had a problem with this. They all say something to the effect of "Okay whatever". I really appreciate all of your input and "reactionary" comments. By the way the pt went home three days post op and is expected to do fine. Yes she has a new scar on her left wrist, but by reading all of your postings - I feel fortunate that is all she went home with.
As with everything we do there is a risk an IM injection is a risk, starting the iv is a risk, the patient lying in hte bed is a risk Phenergan IV is an acceptable order does it burn yes, is there a potential for harm yes, but does it work yes, I use it daily in the ER 5-15 times a day most of the docs I work with order 12.5 iv only had one issue ever come and it was a site in a foot but she had several drugs iv and developed superficial thrombophlebitis. I continue to use give it iv and if called in court My lawyer would aslo present that the drug manfac. only gives a ph that could or could not be inside INS ranges but I acted IAW with hospital standards, IAW with the drug company standards, IAW any drug book I have ever looked in.
But, would that make you feel better, and able to sleep nights, simply because "hospital standards" said it was OK? Do you want to take the risk with your patient's limb--and your license--by saying, "Well, the INS said the pH could be above 5, but then again, it could be below 5. I just took the gamble that pH of the particular IV ampule (or vial) I opened was below 5. HEY! It wasn't! Well, too bad for that patient, but if I am going down, then so is the drug manufacturer, and the doctor, and the hospital." "It's not my fault."
I would really, really look hard at your state nurse practice act--how many RNs have ever even SEEN their's?--and see what your defined role in the way of patient advocacy is. I never looked at MY OWN state nurse practice acts in the states where I practiced UNTIL I had already been an RN for over 20 years. Now, I have to have the applicable state nurse pracitce act in front of me when functioning as a testifying expert on nursing negligence cases in WHATEVER state the act of alleged negligence took place. They all vary in wording--but they all address patient advocacy.
Also, keep this in mind--the jury is given instructions as to what the role of a "reasonable and prudent nurse" is, and that role, and those directions, include attention to patient advocacy.
My own professional organization and governing body AORN, SPECIFIES that we must first and foremost be patient advocates; so does the ANA Code of Ethics. Also, AORN specifies that we must play an active role in establishing policy and procedure, teaching, research, and questioning and actively enforcing change in practices that we believe could potentilally harm a patient.
Although this was an unforseen event in my situation, I now am refusing to give phenergan IVP. None of our ER docs have had a problem with this. They all say something to the effect of "Okay whatever".
Good for you, Lynn!! I admire you for speaking up on behalf of better patient safety.
Giving phenergan IV just to be "mean" is really a dangerous way to go, Tom. Hope you are kidding.
Not that Tom has ever seemed to need me to protect him, but I can't just let this sit.
I read his post (#9 in this thread) to say that the drug's effects can be difficult for the patient to bear (i.e., the drug can be mean), not that he would be.
Maybe you fixed it later on down the line, Tom, so forgive me if I am out of line here.
Besides, I thought route was one of the rights dictated by the doc's orders....
You've made your arguements and presented the facts very well. Obviously not all are going to agree, and some of us are on the fence.
About Dilantin, it's given IV peripherally here for new onset seizures, a large loading dose at that.
Yes, I figured it was in the ER setting, where you do not have the luxury of a qucikly inserted central line, as we do in surgery or as they usually do in ICU. I was just asking about those drugs out of my own curiosity, as I haven't seen them used in soooo long I thought there might be some new IValternatives for acute seizures. Guess not. Isn't it funny how there are now 4th generation cephalosporins, and a myriad of new anesthesia drugs, not to mention all the new AIDS drugs, yet all we have for acute seizures is the same old Dilantin? Guess it'll be around forever; seems like it already has been around forever!
Ive seen far worse extravasations from CT dye over the years
By your reasoning should we stop doing any cts with IV contrast
CT dye extravastions have been the worst Ive seen, far worse than anything Ive ever seen with even Dopamine or even Levophed. Not too mention lil ole phenergan.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
Excuse me, Chris: I would thank you to read ALL the posts, because if you did, you would see I already apologized to Tom and Tom gracefully acknowledged. Thank you. Have a good day everyone. I have enjoyed reading this thread and have learned A LOT, not being an ER nurse!
Not that Tom has ever seemed to need me to protect him, but I can't just let this sit.
I read his post (#9 in this thread) to say that the drug's effects can be difficult for the patient to bear (i.e., the drug can be mean), not that he would be.
Maybe you fixed it later on down the line, Tom, so forgive me if I am out of line here.
Besides, I thought route was one of the rights dictated by the doc's orders....
Ive seen far worse extravasations from CT dye over the years
By your reasoning should we stop doing any cts with IV contrast
CT dye extravastions have been the worst Ive seen, far worse than anything Ive ever seen with even Dopamine or even Levophed. Not too mention lil ole phenergan.
Your inference isn't necessarily correct...you look to see if there's an acceptable safer alternative and you look to see what the (national)standards are as Stevierae has explained, as documented by evidence based research and the like. If there's an acceptable alternative proven safer and effective, it's the prudent practitioner that uses it. Some medications and the like can not be made safer (ie: vaccines which are considered to be unavoidably unsafe and are held to a strict liability standard, a separate topic from this discussion). For instance, if you absolutely must have that CT dye w/ contrast and no other safer alternative exists, you would then place an IV preferably in a large vein, ascertain blood return, document your work, etc. Sometimes people sustain negative outcomes despite the best intentions and care given. This isn't about that, this is about known vessicants that have resulted in negative outcomes and liability issues when there are other alternative medications that treat the same condition without the same risks.
I am having a difficult time understanding how I would ever know the info posted on this BB re phenergan. Every drug book I have looked at on this subject lists IV as a route for the med. I have always relied on those drug books to give the best care possible to my patients when it comes to giving meds. I am not involved with nor a member of the INS, so I would consider myself giving prudent care had I been the OP and chalked it up to a complication. So many meds are hard on the veins, as mentioned here on this thread. Do we just refuse to use ALL of them just b/c there is a chance of a problem? Tell the doc to give all the meds that could cause a possible complication themselves? How is this any different that following P&P, checking the drug book, giving any drug, take lasix PO for example, to find the patient dehydrated or hypokalemic, or any other s/e or complication. We KNOW of the possible complications and watch out for them, but problems do arise. With standards being set by who ever decides to set a standard and then not allow anyone but members be privy to the information is not right and leaves us all open to being held negligent. Of course I would always advocate for my patient to the best of my ability and knowlege, but how can you do that when you have P/P and drug reference books that agree with your own practice standards.
Remember, anyone can sue anyone, for any reason. The hospital will every time try to pin it on the nurse when something goes wrong to decrease thier own liablity, but if you stick to the hospitals P/P, how could you as a nurse be held soley liable?
As far as the sentinal event, that should be used to increase the standards of care to avoid something like this from happening again. The investigation should focus on that issue. They are required to ask the questions they asked of the OP to get to the bottom of the problem and hopefully avoid it happening again.
I don't think the OP caused the complication, esp if the OP followed the P/P and since the books use IV as a route, what else could one do?
I don't know about you guys, but I live in the real world where I am a working mom as well as a nurse. I don't have time to sit around reading all the research there is on all the drugs I give!! I DO have a life you know!! If the doctor orders the drug and the pharmacy stocks it and it is part of the hospital formulary (our pharmacy checks all orders for route/dosage to make sure it is ordered correctly), then that is good enough for me. And despite what you say, StevieRae, the fact that you HAVE given a particular drug LOTS OF TIMES with NO PROBLEMS IS ABSOLUTELY RELEVANT!!! It is evidence that this problem with phenergan is rare given the fact that there are plenty of us who have never heard of it and plenty of us who have given it IV "all the time" and not had our patient's limbs amputated. An all the drug books say it's ok to give IV! If I have never given a particular drug I will look it up and/or call my pharmacist about it with questions. I use my resources. We are all in patient care together, the doctor, nurse, pharmacist, hospital administration. You cannot hold a nurse solely responsible for knowing all the latest research on all the drugs out there. Nor can you hold us at fault because we haven't bought a copy of the INS book and memorized it cover to cover.
I am a patient advocate and of course I strive to take the best care of the patients I serve. But there is only so much I am responsible for! Do I agree with the use of Demerol? No, I hate it, but if it's ordered by a physician and we still have it as part of our formulary and the pt is not allergic then guess what, they get Demerol (doesnt' happen very often anymore, but you get my drift). Would I suggest an alternative? Depends on the physician.
I'm going to spend some time with my husband since I worked a 12 today, while some of you are reading every nursing journal you can get your hands on because you feel you are held liable for knowing all the info contained in them. :chuckle
I've been following this thread. Some posts are good and others are high and mighty.
I'd like to say that while Phenergan burns when given IV, who knows if this is the actual culprit. It seems like the IV in the wrist (a lot of nerves there) could be the problem. When the IV was inserted it could have injured some nerve causing swelling etc... Just my two cents.
I don't know about you guys, but I live in the real world where I am a working mom as well as a nurse. I don't have time to sit around reading
Lynn RN ER TX
9 Posts
Although this was an unforseen event in my situation, I now am refusing to give phenergan IVP. None of our ER docs have had a problem with this. They all say something to the effect of "Okay whatever". I really appreciate all of your input and "reactionary" comments. By the way the pt went home three days post op and is expected to do fine. Yes she has a new scar on her left wrist, but by reading all of your postings - I feel fortunate that is all she went home with.