Deadly medication errors!

Pangea Reunited, ASN, RN · Sep 28, 2015

Luckily, I haven't made a deadly error, but I have made medication errors. The biggest one I made was due to bypassing safety protocols. I gave an urgently needed medication and then scanned it (to save time). After scanning it, I realized it was not the correct medication.

Since I'd given this same medication this same way many times, I was quite confident in what I was doing. So I'd also say the more comfortable and sure you are, the more wrong you can be. Always PAY ATTENTION. I took it for granted that I had the right thing in my hand and I didn't. It looked very similar to the medication I regularly gave and it was next to the correct medication in the PIXIS.

Been there,done that, ASN, RN · Sep 28, 2015

Was this a dosage error?

Facilities SHOULD have a protocol where 2 nurse must confirm dosage of certain medications with adults , and more often with peds. There is also the pharmacy check in place.

Identify the root cause of the error, in order learn from it and prevent it in your practice.

klone, MSN, RN · Sep 28, 2015

What was the error? Wrong med, wrong dosage, wrong route?

blondy2061h, MSN, RN · Sep 28, 2015

Most major medication errors are systems errors. Many hospitals take major precautions now to prevent errors that have historically proven fatal, such as not keeping concentrated versions of potassium that are meant to be further diluted in IV solutions in patient care areas, but having pharmacy deal with those.

Remember your high alert medications- insulin, TPN, electrolyte solutions, hypertonic saline solutions, chemotherapy, opiates, and cardiac medications. Be extra careful with those.

Don't over ride safety mechanisms. If you need a double signer for a medication, make your cosigner actually look. If you have smart pumps, actually get in the habit of programming them by drug name, not just as a basic infusion. Scan medications. Name bands belong no where except on the patient.

Be aware of medication concentrations. Programming a pump for the incorrect concentration of a medication can be dangerous.

Keep an open dialog with your patients about their medications. If you tell them they're getting a new antibiotic, they might choose then to tell you they had an anaphylactic reaction to sulfa at another hospital last year. If you just hand them a cup full of pills, you both missed out on teaching and another safety check.

When errors and near misses happen, report them and keep an open dialogue about them amongst the staff. This is how learning happens and how unsafe protocols change.

Develop good habits early in your career. Taking a blood pressure before giving a beta blocker is time consuming. Giving one to someone with a BP of 80/50 quickly turns into a very time consuming crashing patient. Work these habits into your routine, and they won't seem cumbersome.

This organization has a great newsletter that presents errors and potential errors clearly. The newsletter is pretty expensive, though. Many institutions subscribe. See if your hospital subscribes? It's a good read.

ISMP Acute Care Newsletter Excerpt September 24, 2015

HouTx, BSN, MSN, EdD · Sep 28, 2015

I agree with PP - over the years, I have seen that complacency is a recurring theme in many clinical errors. We become too comfortable with a procedure, med, intervention . . . this gradually leads to disregard of the standardized procedure because "I've been doing it for ___ years & nothing bad has ever happened" or "Everyone else does it this way". Safety analysts call this "Drift".

Sometimes it's very difficult to follow all the steps when we're so very busy but that is exactly the time when errors are most likely to happen.

There is an emerging body of literature on the "second victim" in any medical error - the clinician. HERE is a great article on this issue which also contains information about the suicide of Kimberly Hiatt RN, whose medication error caused the death of an infant in 2010.

SleeepyRN · Sep 28, 2015

Recently a nurse check prevented what could have been a serious error. I work in a rehab facility and our meds are in med carts.

My patient's BP was running around 210/110 throughout my shift. The doctor ordered a few one time orders of hydralazine to try to bring it under 170/90.

Two more doses were due (to be given 1 hour apart) before sending the patient out if we couldn't get it under 170/90.

We had run out of hydralazine in our emergency box so I placed a call with pharmacy stat.

It was change of shift, and I let the oncoming nurse know the situation and that pharmacy would be there very shortly.

The oncoming nurse did not believe me when I told her we ran out of hydralazine.

She went to the emergency box, pulled out a packet of meds, and exclaimed, "I told you so, look it's right here!"

I KNEW we were out. I looked at what she pulled out of the box.

HyDROXyzine!

Sure, give the patient that, allowing his BP to continue increasing, and let him stroke out.

Be aware of look alike sound alike meds. It's SO easy to think you are doing your 3 checks, but really are reading the name of the med wrong.

blondy2061h, MSN, RN · Sep 28, 2015

Recently a nurse check prevented what could have been a serious error. I work in a rehab facility and our meds are in med carts.
My patient's BP was running around 210/110 throughout my shift. The doctor ordered a few one time orders of hydralazine to try to bring it under 170/90.
Two more doses were due (to be given 1 hour apart) before sending the patient out if we couldn't get it under 170/90.
We had run out of hydralazine in our emergency box so I placed a call with pharmacy stat.
It was change of shift, and I let the oncoming nurse know the situation and that pharmacy would be there very shortly.
The oncoming nurse did not believe me when I told her we ran out of hydralazine.
She went to the emergency box, pulled out a packet of meds, and exclaimed, "I told you so, look it's right here!"
I KNEW we were out. I looked at what she pulled out of the box.
HyDROXyzine!
Sure, give the patient that, allowing his BP to continue increasing, and let him stroke out.
Be aware of look alike sound alike meds. It's SO easy to think you are doing your 3 checks, but really are reading the name of the med wrong.

I prevented this exact same error in nursing schools. I was at clinical, shadowing a nurse. One of our patients was getting hydroxyzine, another, hydralazine. The nurse was looking through all the drawers for patient A's hydroxyzine, then exclaimed that she found it, pharmacy had accidentally put it in patient B's drawer. She was holding up patient B's hydralazine. Easy mistake to make.

emtb2rn, BSN, RN, EMT-B · Sep 28, 2015

All of the above and start with ALL weights in kilograms.

SleeepyRN · Sep 29, 2015

I prevented this exact same error in nursing schools. I was at clinical, shadowing a nurse. One of our patients was getting hydroxyzine, another, hydralazine. The nurse was looking through all the drawers for patient A's hydroxyzine, then exclaimed that she found it, pharmacy had accidentally put it in patient B's drawer. She was holding up patient B's hydralazine. Easy mistake to make.

Another one:

I don't recall at the moment the exact med, but one of them was amoxicillin. The other was a look alike ABT. I had one patient getting amoxicillin and another pt getting the other ABT. Well the 2 patients medications were right next to eachother in the med cart drawer.

I gave the wrong ABT to the wrong patient. Luckily no allergy to it or otherwise medical consequence, but the patient's family member realized what I had done because she went and stuck her nose in my drawer. I think because right after I did it, I realized it and I'm pretty sure she saw a certain uh oh look on my face. So she stormed to the med cart with me and demanded I show her what meds I just gave. I didn't have time to close the drawer before she started pointed at meds and other patients names and medications. HIPAA!

Yeah, big whoops. Don't breeze through reading the name of the med.

AmyRN303, BSN, RN · Sep 30, 2015

Always remember your rights of medication, and double check. As for lookalike, soundalike meds, this is a great reference.

https://www.ismp.org/tools/confuseddrugnames.pdf

Nurseling Kathy · Sep 30, 2015

Thank you Pangea. As a student I have pushed Metropolol without confirming blood pressure first. My preceptor had checked before hand and knew it was safe but let me have the experience of panic. It was not meant

to be mean, but to teach, and it did! HUGE!. The BP was within parameters to administer the med, but I didn't know that.