Gave vancomycin wrong

[Simplyvan]

So yesterday I made my first medication error with vancomycin. I had two vials of antibiotics and one was meant to be IV push and the other was meant to hang via infusion. I mixed up both antibiotics and accidentally gave vancomycin IV push.

I instantly realized I made an error.

I assessed the pt and she was fine. I notified my charge nurse and wrote a variance on it. My supervisor was also notified of the medication error. I felt so stupid and dumb for letting something like that happened. I always double check my work but this time I failed. I called the night nurse to see how the patient was doing and she said was fine although that 4am she complained her IV hurt and it was a little swollen but no redness noted. I had given vancomycin around 4pm IDK if that could have caused it. So they D/C the IV and gave her ice. The patient said she felt much better.

As for me, my confidence has gone low. My supervisor told me I could of loose my license over this. Which made me feel even worse. The charge nurse told it was fine, the patient is fine and to take this as a learning experience. This is my third week off of orientation so I’m still adjusting to the environment. I take full responsibility for what happened but I feel so bad about it.

[bsyrn, ASN, RN]

Your supervisor is wrong, you won't lose your license over this so relax. Medication errors happen, learn from it and don't make the same mistake again. Your patient will be fine and so will you!

[subee, MSN, CRNA]

You were lucky...I can't imagine any patient getting IV push Vancomycin without, at least, having an awful case of red man syndrome. Have you made a change in your "system" so that it doesn't happen again. Why was med not already in IV bag before taking it to the room? I still shudder when I remember a med error I made 4 decades ago! I was also lucky and didnt get kicked out of grad school.

[JKL33]

13 hours ago, Simplyvan said:

My supervisor told me I could of loose my license over this.

What did s/he mean by this? Was it supposed to be some kind of threat? Or were they just trying to help you see that being conscientious is important and this situation could have been much worse, as if that needed to be said right then?

It's true that this could have been much more serious, and you and the patient happened to luck out.

Review your practice and make changes where necessary. Then you have to move forward so that anxiety doesn't worsen your ability to be focused and conscientious.

I hope the supervisor can provide some actual support. If not, seek out support and assistance from someone else like your educator or manager as needed.

[Simplyvan]

10 hours ago, subee said:

You were lucky...I can't imagine any patient getting IV push Vancomycin without, at least, having an awful case of red man syndrome. Have you made a change in your "system" so that it doesn't happen again. Why was med not already in IV bag before taking it to the room? I still shudder when I remember a med error I made 4 decades ago! I was also lucky and didnt get kicked out of grad school.

I work in a very fast paced unit. Discharges are happening left and right, patients are coming back from surgery, leaving for surgery and we are constantly admitting patients. It’s a small unit 18 patients, 3 nurses and one tech. We always have four nurses on the schedule but one is always getting floated to another unit. We’ve complained about this because we need four nurses when there’s 18 patients but they don’t listen. I was feeling very overwhelmed. It was a vile of 1000mg of vancomycin in my unit those are not premixed we mix them. When I have to vials of abx I usually separate them but that day I failed too.

This is a reminder to me that I need to go back to my basics. Which is separating them with plastic bags. I learned from this now I’ll be double-triple checking all my medications.

[Simplyvan]

On 12/4/2019 at 11:43 PM, JKL33 said:

What did s/he mean by this? Was it supposed to be some kind of threat? Or were they just trying to help you see that being conscientious is important and this situation could have been much worse, as if that needed to be said right then?

I think she was trying to let me see the seriousness of the situation, but it made me feel much worse.

The unit is very, very fast paced. 18 beds 3 nurses 1 tech. We’ve expressed concern that we need four nurses on the floor but they don’t listen. They always float nurses everyday. Sometimes they have agency nurses come in. When I’m there we are constantly running around all day. We have no secretary so we do all the paperwork as well. I know as a new nurse the first year I’m going to feel unsafe but I feel like the environment I’m working in makes it very easy for you to make a mistake.

What I’m trying to understand if this is just feelings every new nurse has or if this unit is not the right place for me.

[JKL33]

1 hour ago, Simplyvan said:

This is a reminder to me that I need to go back to my basics. Which is separating them with plastic bags. I learned from this now I’ll be double-triple checking all my medications.

Exactly. You must always do the basics. Separating in bags is one thing you could do in this situation, but fully, conscientiously checking and preparing one medication at a time is even better, IMO. For instance, if you had fully, carefully checked your vanco and prepared your piggyback/infusion first, it would have no longer been sitting there in the vial for you to draw into a syringe and push. And you are much less likely to hurt someone if your mistake is infusing something that should have been pushed, rather than pushing something that should have been infused. Create processes that you will rely upon every time with the first goal of eliminating risk of error itself, and then secondarily mitigating the chance of actual harm.

This is an issue in my area where occasionally both IV and IM medications are administered to the same patient. Nurses have their own methods they do every time the scenario arises, such as conscientiously checking 5Rs for the IM med and administering that first and being completely done with it before turning to the IV meds, beginning with making sure you do not have any IM-only meds left to administer. Then follow through one by one, conscientiously checking and administering each IV med.

1 hour ago, Simplyvan said:

I know as a new nurse the first year I’m going to feel unsafe but I feel like the environment I’m working in makes it very easy for you to make a mistake.

You must decide right now, to not let others' decisions become your problem. Meaning, if a decision has been made to stretch the nursing resources thin, that does not mean that you have to hurry endlessly faster and faster. You did not decide on the staffing, but you have the responsibility to do your part to keep the patient safe regardless of the decisions other people made about staffing.

Some things will have to wait. Actual patient care and safety is to be prioritized over every other thing.

If it is impossible to accomplish this, then you must find a place to work where it is possible.

[JKL33]

I kind of hate to give you the debbie-downer side of things, but you have made an error so here it is:

To the employer, stretching nurses very thin is simply "efficient." They believe it is good business practice. But part of the reason that they themselves don't encounter more trouble and criticism for this is because they let safety be the nurse's problem and ultimate responsibility. You're the one with the license and the Code of Ethics. When you rush around because of lack of resources, you are the one who will be directly involved in making a mistake, not them. It will be your fault, and you will be said to be "the" one who could have prevented it.

Healthcare corporations' current ideas of efficiency are only viable because nurses run themselves ragged trying to succeed on their behalf--and in the process take on the risk and the responsibility for errors! Every time you lower your standards just to keep things moving and keep business churning according to the employer's efficiency preferences, you are putting yourself and patients at great risk.

You can't let your guard down. This is like peer pressure on steroids. You have to resist. You cannot lower your standards because of others' demands.

[myoglobin, ASN, BSN, MSN]

Why is it that long since the "To Err is Human Report" we still blame individuals rather than systems that promote errors (as the report suggested we should not). In this case I can think of several "system shortfalls" that may have contributed to the error:

a. Inadequate staffing.

b. The vancomycin should be "premixed" (as it always was in the past). However, to "save money" hospitals have decided in many cases to make nurses mix medicines that would have been premixed in the past (had it been in a 250 or 500ml premixed bag you wouldn't have made the error or risked contamination which is more likely when medicines are mixed on the floor rather than the pharmacy). To me when hospitals decide to "cut corners" like this it is like a driver deciding to drink before they drive. Statistically, it is a virtual certainly that more preventable errors will be made.

What could you do to minimize the risk of this happening again? Well "your system" could be to never walk into a room with an antibiotic that will be IV push along with one that will be hung. Your hospital could even implement a "scan lockout" that would mandate say five minutes between administering an IV push antibiotic and one which was to be hung (although this is no substitute for doing the right thing an premixing the drug). It makes me sick that hospitals make cuts that they know (or should know) will harm patients and destroy careers in the name of incremental profit.

[brownbook]

Can anyone explain how a supervisor telling a new nurse she could lose her license for a med error is the right way to handle this situation?

The supervisor should lose her license or at least her job.

[old&improved]

I agree with myoglobin that this was a systems failure- basically an accident waiting to happen. Given the RNs workloads in hospitals and our frequent rushing around to get our work done in a timely manner it seems unsafe to have a med given 2 different ways on the same patient. I am not familiar with giving vanco IVP followed with hanging a bag. Where I work it is given only by piggyback. I wonder if this is common in many places?

[myoglobin, ASN, BSN, MSN]

Vanc isn't given IV push, but it also isn't "mixed" (we have to mix ourselves in bags). Thus, when we have to give Vanc along with another antibiotic (say cefepime) which is IV push the opportunity is there to make a critical error. If it was "premixed" as it always was in the past, then this wouldn't happen. There is also a greater risk for contamination, or inadequate mixing when the drugs are mixed on the floor. So the hospitals save money, the executives get bonuses, and the patients suffer while the RN's license are put in jeopardy.