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First Med error??

Nurses   (3,916 Views | 20 Replies)

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PDN nurse here. Got to work and see a note saying New prn order for ophthalmic solution atropine for oral secretions, TID. I look at the Mar and see it was last given at 0800 and it's now 2300 so I find the bottle and read the instructions and it's to instill one drop in each eye TID, so I did. Later I was having a conversation about how it isn't seeming to work and the other nurse agreed with me that it doesn't work. Somehow it came up that I gave it in the eye and the other nurse said it was supposed to be sub-lingual. I showed her the note and the bottle and she found the box where it says it's supposed to be under the tongue.

I should have looked for the box and the pharmacists printed instructions and I should have payed more attention to the dates of what "new order meant".

I'm pretty sure this isn't a huge issue, but It's my first error and just wanting feedback.

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VANurse2010 has 6 years experience.

1,526 Posts; 12,853 Profile Views

I'll be honest and say it sounds like you the gave the med without really understanding the pharmacology and what it actually did - and you got burned.

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klone has 14 years experience as a MSN, RN and specializes in Women's Health/OB Leadership.

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Not being familiar with this medication, I can certainly see why one would put ophthalmic solution into the eyes. Just asked my husband and he said "Oh yeah, we use that all the time, it goes under the tongue." I asked why it was called ophthalmic solution if it goes under the tongue, and he said that's how it was originally used, just to dilate pupils.

Did the MAR state sublingual?

I agree with the previous poster that it sounds like you gave it without a full understanding and familiarity of the drug. But as a non-med/surg-ey type nurse, I think it's dumb. It should be repackaged/renamed if it's going to be used sublingually.

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353 Posts; 7,446 Profile Views

No, the Mar was not updated and the bottle was not in the box it came in, so I read the instructions on the bottle.

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JustBeachyNurse has 10 years experience as a RN and specializes in Complex pediatrics turned LTC/subacute geriatrics.

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What did the order and MAR say? Did you contact the pharmacy for clarification?

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klone has 14 years experience as a MSN, RN and specializes in Women's Health/OB Leadership.

6 Followers; 13,573 Posts; 119,354 Profile Views

No, the Mar was not updated and the bottle was not in the box it came in, so I read the instructions on the bottle.

Did you question why you would be putting it in the patient's eyes for oral secretions? I think that would have been my thought process. Of course, my next step would NOT have been "Well hey, let's put this OPHTHALMIC solution under the tongue and see what happens!" I imagine if you've never worked with this med before, it would have been a head-scratcher, especially if the MAR did not specify route.

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353 Posts; 7,446 Profile Views

But once the box was found it clearly said SL... I did do research on it because my memory of atropine was related to the heart, but everything that came up for ophthalmic was right on with what the bottle said to do and was for oral secretions.

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353 Posts; 7,446 Profile Views

I guess my train of thought was it's ophthalmic, the bottle says ophthalmic, the note says new order for ophthalmic... so it goes in the eye. I didn't think to call the pharmacy (not to mention) it wasn't open... I work graveyard shift at someones home.

I know I made an error, thanks for expanding on what I should have been thinking.

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klone has 14 years experience as a MSN, RN and specializes in Women's Health/OB Leadership.

6 Followers; 13,573 Posts; 119,354 Profile Views

Well, I hope you do not get into too much trouble over it. Again, as a nurse who has never worked with any of those types of meds, I could see it as a very easy mistake to make. But it certainly emphasizes the point that nurses are not just automatons who complete tasks, but autonomous care providers who need to always be using our critical thinking skills.

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353 Posts; 7,446 Profile Views

I don't foresee myself getting into trouble... I reported it to the oncoming nurse and she shrugged it off saying it doesn't work either route. I just feel bad because it's my first error.

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klone has 14 years experience as a MSN, RN and specializes in Women's Health/OB Leadership.

6 Followers; 13,573 Posts; 119,354 Profile Views

I get it. Think of it this way - your first med error, and nobody was harmed or killed. You got it out of the way, and I bet you will NEVER make that or similar mistakes again. A pretty inexpensive lesson learned. There's a saying I really like:

Good judgment comes from experience. Experience comes from bad judgment.

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