Deadly medication errors!

[Nurseling Kathy]

I have three months left until graduation, exciting and daunting all at the same time. We recently had a medication error that resulted in a child's death at a local facility. I cannot even begin to imagine what the family is feeling or what the staff member that administered the wrong dose is going through. It can happen to just about anyone So, what can I do personally to avoid this tragedy?

[Nurseling Kathy]

Thank you all! 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.

[Nurseling Kathy]

Oops, didn't mean to post the same reply twice! Rookie I am! :)

[NRSKarenRN, BSN, RN]

Moved to AN's Nursing and Patient Medications has tons of articles and threads re medication safety tips.

Institute For Safe Medication Practices has the best advice regarding medication safety and prevention of med errors. One can sign up for their newsletters or peruse their Quarterly Action Agenda with FREE CE for nurses.

[Nurseling Kathy]

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

To respect all the parties involved, we don't have a lot of details. I believe it was the wrong med, adult size dose to a child.

[azhiker96, BSN, RN]

Great advice given so I can only add a little. I half jokingly say it helps to have a touch of OCD with medication administration.

Sometimes people or systems will accidentally try to trip you up.

One time I got a 14 yr old fresh from surgery. He had a nearly empty bag of LR and a fresh bag of fluid hanging beside it. Anesthesia gave me report and said the kid was dry and would need the second bag of LR. When the LR was ready to replace I looked at the second bag but the writing was on the other side and didn't quite look right. I turned the bag and saw it was mannitol. That is exactly what he didn't need.

I know of a couple of errors helped by Pyxis. When you select a med and a single location opens up, you expect that to have the needed medication. In one case, pharmacy had loaded the wrong iv narcotic in the location.

In the other case, the nurse had accidentally selected the medication listed above the one she wanted. Those touch screens sometimes need calibration and will think you're touching it up to half an inch from where you do touch it.

One final thought. We also catch errors by the doctors and sometimes pharmacy. I've sent back meds that were mixed in the wrong solution. I've also caught wrong med or dose as written by providers. They are always sheepishly thankful for those calls.

Doctors, pharmacy, and nursing are all a team but nurses happen to be the last chance to ensure the patient gets the correct med/dose/route and so forth every single time.

I've made mistakes, nobody is perfect. But that is when your character has a chance to shine. Immediately mitigate if you can, such as stop the infusion, and call the doctor. Most doctors are matter of fact, will accept your apology, and direct you from there.

[RainMom]

If you have barcode scanning, USE it. I've had to write up 2 incidences in the past 18 months or so because I found the wrong abx hanging in pts' rooms at the start of my shift.

At some point over the past yr, my facility also had a huge med error involving a peds pt who received an adult dose of an abx. The MD entered the wrong dose based on wt & overrode the warning prompt that came up. Pharmacy verified the incorrect dose. The nurse overrode the warning again that popped up when it was scanned & then administered it. Not sure when the error was discovered but from what I heard, there was no injury. Everyone received education on med admin & heeding any warnings that pop up when you scan a med.

[BuckyBadgerRN, ASN, RN]

This is older, but made national headlines:

Nurse Charged With Felony in Fatal Medical Error

[Nurseling Kathy]

Sorry I am getting back to this so late BuckyBadger. I read the article you included. How unfortunate for everyone involved. It scares me how easy it can happen. I watched a NICU nurse give a seemingly innocent dose of vitamins to the wrong twin just last week. HCP said it was harmless, but it can happen so easy. I am not sure what has happened with our local case. It seems to have gone away and they are not telling us students any more about it. Thank you for the article. :)

[Lev, MSN, RN, NP]

We've had the pharmacy load the wrong med into the pyxis more than a couple times. Always look at what you take out of there.