Following a nurse who made a huge error....

[New CCU RN]

Without going into much detail because of privacy issues, the other day I followed a nurse who made a huge med error which I discovered. It did cause a potentially life threatening adverse reaction. I notified my manager, risk management, and of course the physicians.

I guess I still feel like more should be done in order to avoid this problem again. It was a mistake as a result of not understanding the rationale behind a therapy we were giving the patient. Rather than consulting the MD, she took matters into her own hands and assumed a dangerous drip should be titrated.

If you were in this situation... what else would you do? Is there anything left for me to do?

I am heartbroken particularly for the patient bc he was beginning to turn around and start to improve and this mistake may cost his life.

[moonshadeau, ADN, BSN, MSN, RN, APN, NP, CNS]

Reminds me of the first thing that I learned out of nursing school.

"if you don't know...ask"

[obillyboy]

So here is another fine example of what not to do a nurse was giving vistaril to a pt. the INT in the left hand flushed but then when she tried to push the vistaril it " seemed slugish" so she flushed the INT in the right arm it went well so she finished the push in that INT.

So anyone whant to guess what happened.

Necrosis started and was found by another nurse it was all written up and the girl still works there, but now the pt has since undergone 4 grafts that i know of.

This is what not to do .........................NO VISTARIL IV

[delirium]

I just wanted to add to everyone's statements here.

You did an awesome job, finding the error, and notifying the appropriate people. I hope the patient is able to recover, and that something good will come out of this... identifying what occurred, changing the system, etc. I always feel badly for the nurses involved when I hear stories like this.

[ceecel.dee, MSN, RN]

Were the Dr.s orders clear?

Was his/her plan clearly laid out?

Obviously the nurse should have asked if she didn't know, but with a commonly used med being used in an umcommon way...could it have been easily missed....with the doc sharing some of responsibility here?

Great job to you...for catching the error...and for caring so much about the outcome!

[susanmary]

It's a difficult situation for everyone involved. You filled out the incident report, the manager was notified -- now it's out of your hands. Can't imagine what that nurse was thinking -- she can explain herself to management. Hopefully, the patient will recover. Also, we can all learn from this incident.

[mattsmom81]

I think we have to be extra careful...specially with drugs involving standing orders and protocols. I have worked in units that slap that drug protocol on the chart whenever the drug is ordered....without directly addressing the physician for specifics. Then if/when the doc writes one order outside the protocol the question remains...are we following any or none of this protocol or not?

Personally I've found protocols seem to be a substitute for some nurse's critical thinking.... they shouldn't substitute for doctor orders and communication but too often they do. And it's such a source of potential error. I've had to call too many docs at 2 am to clarify conflicting orders in my critical patients' charts, only to find the protocol was placed in the chart when the doc did NOT intend it.

I don't know if protocol was involved in this OP's story or not but it's the first thing that jumped into my mind as I've seen similar situations.

As far as what you can do, that's your call...you can speak to this nurse alone if you wish as a professional FYI or let your director handle it. I know these situations are hard to see..I've been there. Hang in there.