Med Errors

Pediatric Critical Care Columnist · Dec 10, 2004

I once gave an infant 10 times the ordered dose of propofol. She needed handventilation for about 15 minutes, until it wore off. Wrote that one up myself. I also had a near-miss years ago when a coworker was struggling to keep a patient from climbing off the bed and asked me to give Ativan... it's over there on the counter. I pick up the 1ml syringe on the counter and have it in the port on the stopcock before I notice it's pancuronium... The kid never got any, and once I located and gave the correct drug, I cleaned up the bedside. No more pancuronium laying around for this little extubated kid!

New grad just off orientation gave an infant captopril via CVC. In the middle of morning rounds. With the rounding staff standing by the bed. Good thing since the kiddie arrested. He survived, but we'll never know for sure if there are long-term effects, due to his underlying problems.

New grad six months on the job in PICU mistook the balloon port on a Foley catheter being used temproarily as a GT for med port (thought it was so cool to have a med port that had a valve in it!) and gave a shift's worth of GT meds into it, including several doses of chloral hydrate and furosemide. Guess what happened when the balloon finally broke? Yup.

Kiddie comes back from OR post renal transplant to a PICU slammed with admissions and insufficient staff. Nurse is mixing up infusions as ordered by the nephro team. Order reads "Wt 12 kg. Morphine 180 mg in 125 ml NS - 1 ml/hr = 10 mcg/kg/hr (120 mcg). Start at 40 mcg/kg/hr." She proceeds to mix it as written, second nurse reads the order, looks at the drug drawn up in the syringe- both match- signs off on the infusion and goes back to her crumping post-op heart. Kid gets 4 ml/hr of this infusion (5.76 MG/ hr!!) for more than a day before it was picked up. Nice that he was intubated...

This quaternary care center of 650 beds and 8 ICUs does not have a pharmacist in house between 23 and 07 ever. If the med you need on nights isn't in your Pyxis, it might be in the "night cupboard". A security guard goes and gets it. Hmmm.

BrandyBSN · Dec 10, 2004

My first med error I made the first week out of school was I gave a patient fortaz instead of rocephin. Dr had written it in generic, and these two drug have very close generic names. No harm to the patient, but I did have to write myself up.

I gave Vistaril IV for a patient that has chronic migraines, along with demerol, benadryl, toradol, bumex, ativan and phenergan (all IV as ordered), but I missed the Vistaril being an IM order. I didnt catch that one, but got a note about it in my mailbox.

To my knowledge that is the extent of my med errors.

I have seen magnesium giving instead or morphine.RNs gave diprovan (as ordered, but our hospital policy says anesthesia must give it) I know there are others, i just cant think of any tonight

tshores · Dec 11, 2004

In a post CABG patient, Tridil turned off in a peripheral line--then a few minutes later, pt. was bolused with NS in the same line. Of course, there was still Tridil in the tubing and the BP plummeted--this can happen with any kind of medication, though.

New grad came out of a pt.'s room asking how we measured NTG ointment to make sure it was an inch as she rubbed her hands together. Said she felt all right, but I made her wash her hands with soap and water immediately, showed her how to use the papers and scolded her for not asking first. She'd put the paste on her hands and rubbed it on the patient's chest.

Lidocaine bag instead of heparin flush bag under pressure on an arterial line.

Two instances where Verapamil was pushed rapidly and it straight-lined the patients--got one back pushing calcium, the other died. The one we got back was in his 40's and the other one was in his 70's, and it should always be pushed slowly in the elderly or in anyone taking beta blockers--and sometimes it happens anyhow. I know a lot of nurses always slam it in, but I don't. You only have to see it once, no matter who actually pushed it, to make a believer out of you. Saw this once with Inderal with the second mg (in 9cc of NS) slowly pushed 20 minutes after the first mg--only that patient went bradycardic then asystole and all the atropine and epi never touched him (not really a med error, but we really have to respect these big gun drugs we use).

Before pre-mixed lidocaine: came on one night and the off-going nurse said she'd put 2 gms in 500 cc D5W, but she held up 2 100 mg bolus amps to show me what she'd put in the bag, swearing that there was 1 gm in each amp and said the pharmacist had assured her of that when I told her she'd need 10 of those to make 1 gm. The patient had an MI and was having PVC's all over the place. I mixed another bag, the patient responded, and she didn't talk to me for a while after that.

And I'm sure there's a lot more I can't think of right now.

EMTI19 · Dec 11, 2004

Caught a med mistranscribed onto the MAR at my last clinical. Doctor's hand-written order was for 20 mcg (with decent legible handwriting) and the MAR listed 20 mg. Lesson learned in clinical: ALWAYS check the MAR against the written orders....

note:this was the pt's 3rd day in the hospital and had been receiving this med (can't remember the name of it right now) every day.

RNLaborNurse4U · Dec 11, 2004

I work in L&D. We kept our premixed pitocin and magnesium sulfate bags right next to each other on a shelf in our med room. Both are 1000cc bags.

A very seasoned nurse grabbed a bag of pitocin to run rapidly after a lady partsl delivery. Patient became unresponsive during laceration repair. Midwife looks up and sees that it's magnesium sulfate running wide open - not pitocin. Infusion stopped, calcium gluconate given, and pt recovers.

Now we have only 500 cc magnesium sulfate bags and they are on a different shelf in the med room, further away from the pitocin bags.

Both drugs are clearly labeled, with bright pink stickers on the pit bags and red stickers on the mag bags.

I still see a problem with them being stored close to each other, even though they are different size bags now.

Goes to show - even if you're in a rush - CHECK YOUR MEDS AND IV SOLUTIONS!

I really really wish we'd go back to mixing our own pit again. This would not have happened if we didn't have the premixed pit bags.

mattsmom81 · Dec 13, 2004

After so many years in nursing I feel this way about med errors. Many of them occur only because the nurse is overworked, stressed and rushed...trying to do more than one person can do in the time she has. When another nurse lectures and says 'there's no excuse' I wonder if we work in the same environment. It seems today there is so little support for us on the job, and we are not getting what we need to be successful in the workplace. Like we are being set up to fail so we can be scapegoats.

I feel more and more like the workplace itself today is just a 'mistake waiting to happen', with the workload, short staffing practices, the endless tasks and paperwork, the endless demands. No wonder there is a 'shortage' and so many nurses will not work as nurses any longer.

crmdy423x · Dec 17, 2004

Pitocin IV set up to be given without being piggy-backed to Lactated Ringers.
Caught before administered.
Procardia almost given instead of a prenatal vitamin.
Caught before administered.

At our hospital Pitocin is placed by the pharmacy in LR before it is brought to the floor for administration. MGSO4 and Heparin are also mixed by the pharmacy now, not together. This has resolved many med errors, i'm told.

crmdy423x · Dec 17, 2004

Pitocin IV set up to be given without being piggy-backed to Lactated Ringers.
Caught before administered.
Procardia almost given instead of a prenatal vitamin.
Caught before administered.

At our hospital Pitocin is placed by the pharmacy in LR before it is brought to the floor for administration. MGSO4 and Heparin are also mixed by the pharmacy now, not together. This has resolved many med errors, i'm told.

crmdy423x · Dec 17, 2004

Pitocin IV set up to be given without being piggy-backed to Lactated Ringers.
Caught before administered.
Procardia almost given instead of a prenatal vitamin.
Caught before administered.

At our hospital Pitocin is placed by the pharmacy in LR before it is brought to the floor for administration. MGSO4 and Heparin are also mixed by the pharmacy now, not together. This has resolved many med errors, i'm told.

crmdy423x · Dec 17, 2004

Pitocin IV set up to be given without being piggy-backed to Lactated Ringers.
Caught before administered.
Procardia almost given instead of a prenatal vitamin.
Caught before administered.

At our hospital Pitocin is placed by the pharmacy in LR before it is brought to the floor for administration. MGSO4 and Heparin are also mixed by the pharmacy now, not together. This has resolved many med errors, i'm told.

netteh1, BSN · Jan 1, 2005

undefined

You can't give Vistaril IV? Huh, it SEEMS like we used to give it all the time--in combination with Demerol--in very early labor for pain relief (granted, this was back in the '70s, before anyone had even HEARD of epidurals.) Maybe my memory is faulty, and we gave it IM.
I can't say I've even seen Vistaril used in any operating room setting, even IM, since Versed became available--but I have heard it is still used in ER settings for migraines--perhaps also in combination with Demerol.
What's the reason that it should not be given IV?
OK, maybe 5 years ago, I was circulating on a D&C for retained placenta. We had a Pitocin drip going to control the resultant post-partum hemorrhage, but her uterus remained boggy, and just wouldn't clamp down.
The anesthesiologist resident attempted to give Methergine IV. I stopped him and offered to give it for him I.M. in the deltoid, (and did so) because I was trained to never, ever give Methergine I.V.--as its effect is on the smooth muscle of the uterus, it should be given I.M., and, in fact, since the lady was already up in stirrups undergoing a D&C, the ideal route would have been to have the surgeon inject it with a spinal needle directly into the uterus, or even paracervically.
Now, I've since learned that you CAN give Methergine I.V. but it's not recommended except as a last resort, because it can preciptiate a hypertensive crisis or even a CVA. Anresthesiologists tend to give everything rapid IV push, and I shudder to think what this lady's outcome would have been had he proceeded to do so.
How about the rest of you? Have you ever seen Methergine given I.V.? Could it have just as easily been given I.M. in the situation in which you saw it done, and did the patient suffer an acute hypertensive crisis?
We also had to give this lady Hemabate and transfuse her.

Several Years ago a nurse did give Vistaril IV and the patient went into 3rd degree heartblock. According to the pharmacist it is not the medicine that causes the problems but the diluent that is used in the medication.

ER_RN21 · Jan 2, 2005

You can't give Vistaril IV? Huh, it SEEMS like we used to give it all the time--in combination with Demerol--in very early labor for pain relief (granted, this was back in the '70s, before anyone had even HEARD of epidurals.) Maybe my memory is faulty, and we gave it IM.
I saw Vistaril given IV ( the IV was in the foot) and the phelebitis and tissue necrosis was so bad the pt. almost lost her foot. . . you could trace the vein clear up her leg and almost past her hip. . . it was SO bad, I will never forget it. It was an agency nurse.
The other huge med error that I can remember was when Ca++ infiltrated into a pt's hand and she almost lost her hand, it was really bad too. . Her fingers, nails and the back and bottom of her hand were the blackest that I had ever seen, worse than any necrosed tissue in a decube. And then to top it all off, the MD wrote in the H&P " L hand necrosis secondary to Ca++ infiltration. I did not think you were EVER suppposed to do that!!
These are the 2 med errors that stick out the most for me that I have seen so far. (I just finished school, but have been a tech for 5 yrs).
Thank you for all the information that everyone shares here. . . it is WONDERFUL!!!