Er, let's watch what we're doing here, ok? Thanks

Nurses General Nursing

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Specializes in CCU & CTICU.

I got this pt last night. Comatose, DNR, on pressors but as per the family, the doc's changed the parameters of the DNR so we're not to increase the pressors if the blood pressure decreases.

The blood pressure had been pretty marginal but in the middle of report (of course) it starts to fall further. I go in there and the MAP is 39-40. PA calls the family.

I take a look at my drips and there's Levaquin hanging instead of Levophed. :no:

I guess the previous nurse didn't realize Levophed isn't the only med that comes in a "protect from light" brown bag. But that's still not an excuse for this nurse to not look at what they were hanging. :no: Pharmacy will send you weird things. I've had meds labeled by the company (like Levaquin) mislabled at my old job (Pharmacy thought it was Flagyl).

Needless to say, pt survived my shift.

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Good Lord...........

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Specializes in LTC, ER.
I got this pt last night. Comatose, DNR, on pressors but as per the family, the doc's changed the parameters of the DNR so we're not to increase the pressors if the blood pressure decreases.

The blood pressure had been pretty marginal but in the middle of report (of course) it starts to fall further. I go in there and the MAP is 39-40. PA calls the family.

I take a look at my drips and there's Levaquin hanging instead of Levophed. :no:

I guess the previous nurse didn't realize Levophed isn't the only med that comes in a "protect from light" brown bag. But that's still not an excuse for this nurse to not look at what they were hanging. :no: Pharmacy will send you weird things. I've had meds labeled by the company (like Levaquin) mislabled at my old job (Pharmacy thought it was Flagyl).

Needless to say, pt survived my shift.

Yes I have heard of that happening with the levophed and levaquin. that's why even in emergency situations, take the time to read the label carefully. I wonder how long that levaquin was hanging, because outside of a code situation, don't folks routinely double check the pump, and the fluid/med that is hanging when they go into the room to check the patient. I wonder why that wasn't caught. I hope you wrote an incident report on that one, cause that was bad. Good for you for being dilligent about not just taking her word for it, the pt probably would've died.

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Specializes in Onco, palliative care, PCU, HH, hospice.

Wow.... It's amazing that patients survive some of the things we do to them.

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Specializes in ER, Med-Surg,Oncology,FNP.

I was always afraid of levophed, because we have to mix our own cardiac drips. That made me nervous. Now I'm glad we do. That is scary.:eek: Glad your patient survived.

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Specializes in ER.

Well, she won't be needing blood cultures this shift...

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Specializes in ICU.

Wait a sec... isn't levaquin yellow in color? And I've never seen Levophed come in a "protect from light" brown bag. Only Nipride and some other abx...

I'm confused

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Specializes in Neuro ICU and Med Surg.

I have never seen either in a protect from light bag. Levaquin is yellow and Levophed is not. How the heck do you get them mixed up?

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Specializes in CCU & CTICU.
Wait a sec... isn't levaquin yellow in color? And I've never seen Levophed come in a "protect from light" brown bag. Only Nipride and some other abx...

I'm confused

I had seen the bag on occasion at my old job for both of those meds, but it's used all the time at my current one. I was trying to figure out why but every ref I find says "protect from light" in reference to the med while it's in the little bottle.

I have never seen either in a protect from light bag. Levaquin is yellow and Levophed is not. How the heck do you get them mixed up?

Our light bags are brown semi-transparent plastic bags which covers the whole med bag, the previous nurse had just grabbed the whole thing and hung it, assuming it was Levophed. I almost fell over when I saw the tubing was that yellow-green color.

Personally, I'm more suprised they didn't notice based on the size/weight diff. Levophed is 250ml, more than twice the size of those little Levaquins.

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Specializes in Gyn Onc, OB, L&D, HH/Hospice/Palliative.

I once had pharmacy send me a bottle of nitroglycerin in place of multivitamins- they use to be dispensed in the exact same brown bottle with red rubber stopper, could have killed her. Another time they sent me prostin suppository (labor inducer) instead of progesterone suppos for an IVF pt who was just successfully pregnant after years of infertility.. ALWAYS READ THE LABELS, no matter how familiar you think you are with packaging

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Specializes in Home Care, Hospice, OB.

long time ago, in a galaxy far, far, away....

my mother-baby unit used to store nacl and kcl on the same shelf, in the same sized vial with same colored labels..after a very close call, the kcl was changed to another manufacturer and another storage area!!:uhoh3:

same unit, i mixed rubella vaccine instead of pitocin into an iv--you guessed it, similar vials, side-by-side in 'fridge. caught it before i spiked it, only because the "check it three times" rule that had been pounded into my head. diane wink, where-ever you are..thanks!!:bowingpur

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Specializes in Gyn Onc, OB, L&D, HH/Hospice/Palliative.

I remember those days with the KCL.. bad things use to happen, oh yeh, I almost pushed Gent instead of heparin to flush a central line , same 1cc little vial, same manuf, same color label and type, that was back in the day when pharmacy dumped all the meds for each pt in the med cart, I still see wrong things loaded in the PYXIS tho, hey humans load them......

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