This morning I had admission that came up from the ED. Her blood pressure was high with SBP in the 190s and the pulse was hanging around the high 90s/low 100s. The doctor saw her and put in a STAT order for IV labetolol and I gave it without question over the recommended 2 minutes for the dose I gave. She was on a cardiac monitor and I was watching the rate and rhythm closely. No adverse effects were noted, and the vitals were stable a half an hour, 1 hour, and 2 hours after administration. My shift ended and I left. I had no worries about the care I provided .
I am still relatively new on my floor, and during my inevitable post-work anxiety nightmares, I dreamt I was being fired for administering this drug. Somehow, my waking self did not remember a comment that I received once, roughly 6 months ago in orientation, about IV labetalol, but my subconscious pulled it up no problem. We are not supposed to give it on our floor (though IV metoprolol is okay) and it needs to be administered in an ICU/CCU setting.
When I am back at work, I am going to complete an incident report and inform my charge nurse but I am very fearful. I know med errors happen, but I just feel awful and cannot help but think of all the "what ifs" as far as the patient's health and my own job. I doubt any one has been in these exact shoes, but any input is appreciated. I am so worried and full of regret.
This stuff happens in a large facility and I agree with the posters who say pharmacy would be helpful here as the policy gatekeeper. Also, I wonder if this is a hybrid floor with some unmonitored beds? We have some floors like that and there are certain interventions you can only do on monitored patients.
Ive even gotten a call notifying me that one of our VAD patients had been admitted to oncology and they initiated a milrinone drip. (We are the only unit able to take VADs besides CICU; it doesn't matter if they have a stubbed toe or a brain tumor, they come to us) Even the charge who approved the bed and transferred the patient up from the ED and the house sup missed it, apparently. The hospital was at capacity and I'm sure they were focused on getting the patient out of the ED.
We have 24 hour pharmacy and the house sup on speed dial for these issues since we take a wide variety of acuities, drips, and the like. To me, the bottom line is the best interest of the patient. For systolic of 190, what would be the best response? Ideally a quick phone call would be made but...Obviously the doc wanted to get that pressure down. While that isn't crazy high, There may have been extenuating circumstances that warranted emergent treatment.
The nurse administered the med correctly (if BP was monitored). Sometimes you need to treat the issue and transfer later. It was a one time dose as well, by the sounds of it.
We allow Metoprolol but not Labetolol on my unit as well, and I'd be willing to bet that this is exactly why.
They are both types of beta-blockers, but they are not identical in mechanism of action.
Metoprolol selectively blocks mostly beta-1 receptors in the heart. So it lowers BP by decreasing cardiac output (it can lower heart rate and decrease contractility).
Labetolol blocks beta AND alpha-1 receptors. So it does everything that metoprolol does, but also causes vasodilation - decreasing BP further by lowering systemic vascular resistance.
I wonder if that is why they allow metoprolol but not labetolol.
I would have given the med policy or not. Neither metoprolol nor labetolol have that profound effect on heart rate and blood pressure that would warrant the patient being on anything other than a basic Telemetry floor. Take a baseline HR and BP, give the med, recheck HR and BP in 5-10 minutes and you are done.
I would have given the med policy or not. Neither metoprolol nor labetolol have that profound effect on heart rate and blood pressure that would warrant the patient being on anything other than a basic Telemetry floor. Take a baseline HR and BP, give the med, recheck HR and BP in 5-10 minutes and you are done.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
To been there done that, I do know my meds. Labetalol (trandate), not lopressor. Both beta blockers, however one is approved and the other is not. And yes, in response to boomer, it seems like a silly rule and I'm sure when I bring it up to other more experienced nurses, they'll talk about how it is a little odd. But it is policy and I do wish I had remembered it. I know it's silly it came to me in a dream, but it doesn't change the fact that I did do something my facility does not agree with.
Please use the "Quote" function so we can all follow the thread. Thanks.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
Everything you have written here tells us that you already know what you are going to do. There is no wavering in your decision, you are quite clear that you are going to be turning yourself in and placing your head on the chopping block if they ask you to. What is it you're hoping to get by posting the thread if nothing anyone says will change your mind? Do what you need to do. Then move on.
The thread is valuable, if not for the OP who has already made up her own mind, for the other newbies who might receive an order for a drug that is not on their approved IV push list. If they receive an order like that, the first thing is to check the IV push list -- they're usually on the hospital's intranet and if they're not typed up in an easily searchable list, there's a project for someone looking for a few brownie points or a promotion. If the medication isn't on the approved list for your unit, tell the provider who ordered it. They can change the order or initiate a transfer to the ICU or you can pull the drug from the Pyxis and they can push it themselves. (Just make sure it's a drug that SHOULD be pushed -- I did see a new grad nurse tell an intern that 'we can't give anything more than 40 mEq in 500cc here on the oncology floor, but if you want to push it, you can give as much as you want.' The intern in question was about as experienced as she and actually drew up 40 mEq of POTASSIUM Chloride and was about to push it in a little bitty vein in a little bitty old lady with a K+ of 3.5.)
Another point -- if you're having the provider push the medication because it's against hospital policy for you to do so, make sure you know WHERE they're pushing it and that it's an appropriate place for that medication to be pushed. I once saw an intern (love those interns!) push Dilantin through the TPN line.
It made a really impressive ball of white precipitation in the line -- rock hard -- which fortunately burst the IV tubing before it got all the way to the patient as a rock hard embolus.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
Would this technically be considered a medication error? It was an ordered medication. Legally any RN can administer this medication and it was given within parameters. More like breaking policy and procedure...but a med error? I am just curious, only having ever working in critical care...feel free to correct me lol
Different facilities may answer this one differently, but yes, it is a med error. OP's facility prohibited administering this medication on the floor rather than in a critical care unit.
It made a really impressive ball of white precipitation in the line -- rock hard -- which fortunately burst the IV tubing before it got all the way to the patient as a rock hard embolus.
"This morning I had admission that came up from the ED. Her blood pressure was high with SBP in the 190s and the pulse was hanging around the high 90s/low 100s. The doctor saw her and put in a STAT order for IV labetolol and I gave it without question over the recommended 2 minutes for the dose I gave. She was on a cardiac monitor and I was watching the rate and rhythm closely. No adverse effects were noted, and the vitals were stable a half an hour, 1 hour, and 2 hours after administration. My shift ended and I left. I had no worries about the care I provided . "
Based on your story, from this one incident, it seems like you did a great job and it sounds like you are very conscientious with the things that you do as a nurse. But yes, certain floors do have their own P&P for certain medications you can and can not give.
I would have given the med policy or not. Neither metoprolol nor labetolol have that profound effect on heart rate and blood pressure that would warrant the patient being on anything other than a basic Telemetry floor. Take a baseline HR and BP, give the med, recheck HR and BP in 5-10 minutes and you are done.
Hopefully you never work in a facility that holds it's staff members to the standards of ALL their policies and procedures, not just the ones that staff member happens to agree with. Willful violation of policy is grounds for termination and if your attitude is that you know better, and you'll do what you want regardless, your career is likely to be quite short.
kalycat, BSN, RN
1 Article; 553 Posts
This stuff happens in a large facility and I agree with the posters who say pharmacy would be helpful here as the policy gatekeeper. Also, I wonder if this is a hybrid floor with some unmonitored beds? We have some floors like that and there are certain interventions you can only do on monitored patients.
Ive even gotten a call notifying me that one of our VAD patients had been admitted to oncology and they initiated a milrinone drip. (We are the only unit able to take VADs besides CICU; it doesn't matter if they have a stubbed toe or a brain tumor, they come to us) Even the charge who approved the bed and transferred the patient up from the ED and the house sup missed it, apparently. The hospital was at capacity and I'm sure they were focused on getting the patient out of the ED.
We have 24 hour pharmacy and the house sup on speed dial for these issues since we take a wide variety of acuities, drips, and the like. To me, the bottom line is the best interest of the patient. For systolic of 190, what would be the best response? Ideally a quick phone call would be made but...Obviously the doc wanted to get that pressure down. While that isn't crazy high, There may have been extenuating circumstances that warranted emergent treatment.
The nurse administered the med correctly (if BP was monitored). Sometimes you need to treat the issue and transfer later. It was a one time dose as well, by the sounds of it.
Maybe I'm more blasé because I work cardiac and critical care, but I don't see this as a huge deal - rather, as others have stated, it's a chance to clarify policy and educate all the staff involved.