Sorry in advance for the long post, but you need to know the events preceeding.
Two days ago we had a Code Blue in our area & pt needed epi SQ. Myself & a fellow nurse were the first to respond. Our carts don't stock epi (a whole other issue!:angryfire) so the responding team had to go to an PACU area about 500 feet or so from us to get 2 vials to administer. Pt transferred to the ER with no further incidence. It was commented by several nurses that responded for the code that epi should be on inventory for crash carts.
Yesterday, we had another Code Blue. Once again, I was the first responder. Pt could not get her epi pens to work. Those around her had tried 2 different pens. Attending ER doc comes up & pt is wheezing loudly by this point & on O2. I advised that epi pen malfunctioned & he ordered someone to head to omnicell for dosage. I told doc that I carry one in my purse & asked if he wanted it. I was told to get it asap. Ran back to desk, got pen, returned & adminstered epi per order. Six minutes after I injected epi, the new Officer for pharmacy comes in with epi vials. She was told pt had already received epi & to return med to omnicell. Officer demanded to know how epi was obtained & I told her it was my personal epi pen. She was furious to say the least & has threatened to write me up for the incident.
To make a very long story a little shorter, turns out that the pt was seen in ER by same doc day before for reaction & rx'd epi then. Pharmacy here filled with above mentioned Officer actually instructing pt on using epi pens. Officer gave the pt the wrong instructions for use & that is why the pens malfunctioned!! Had the pt been at home, she would have died. When the doc found out that pharmacy was having a fit, he said in so many words that they could kiss all of our ****. Pt was sitting there & heard the entire discussion which is how we discovered she'd been given wrong instructions. Today, I went down to pharmacy to turn in our order list for tomorrow's surgeries & was asked by a friend in there what happened yesterday with me giving my pen to the pt, he had heard about from the Officer who apparently returned to her unit talking about me.:angryfire
I feel like I did the right thing & would do it again today if the need arises. Granted, if it were any other, non-emergent issue, I would never give out personal med, but it is standard dosage with standard self-admin system. I don't feel like I am in the wrong. Should I file a variance on the Officer for giving the pt incorrect instructions that could have cost her life?
BTW, pt sent me a fruit basket taking with note that says "Thanks for saving my life." I cried.
Specializes in Triage, MedSurg, MomBaby, Peds, HH.
Lil D, you're my hero. You exposed yourself to some criticism/liability, sure. But you did it so save someone's life. That's what it's all about, in my opinion. :)
When the doc found out that pharmacy was having a fit, he said in so many words that they could kiss all of our ****. Pt was sitting there & heard the entire discussion which is how we discovered she'd been given wrong instructions. Today, I went down to pharmacy to turn in our order list for tomorrow's surgeries & was asked by a friend in there what happened yesterday with me giving my pen to the pt, he had heard about from the Officer who apparently returned to her unit talking about me.:angryfire
graceomalleyRN, RN
249 Posts
Lil D, you're my hero. You exposed yourself to some criticism/liability, sure. But you did it so save someone's life. That's what it's all about, in my opinion. :)