Med Error Advice...

  1. I work as an LPN at my hospital emergency department. I am a new nurse (5 months) and stared out in the ED. On my last shift we had a patient that had just returned from radiology. I was helping the xray tech getting him hooked back up on vitals monitoring and I reattached his IV line and unclamped the line. I went back to my desk and was working for roughly 5-10 minutes when patient's RN came and asked me if I had started the Vancomycin in room 3. I said that I hadn't, thought for a moment and realized I had hooked this patient back up to his bag of fluids. She told me that it was Vanc and I had just bolused the patient. My heart sank! I did not ask the RN or even think to check the bag. She told me that you don't bolus Vanc, which I know that it has to be infused roughly over 1-2 hours. I immediately called my supervisor to let her know what happened. I also filled out an incident report. I monitored the patient for any adverse side effects for the duration. Thank God their weren't any. I made a mistake and owned it. But at the same time, I feel as though I wan't COMPLETELY to blame for this error these reasons: 1. vancomycin must be infused with a pump and that the line must be on a pump when the bag is hung. The RN did not attach a pump to the infusion line or on the IV pole. The nurse said it was sitting on the cabinet. 2. At our facility, as I am sure with any other, when you mix a med in a bag of fluids you must attach an orange sticker to the bag indicating what has been mixed. There was no sticker on the bag of fluids indicating any drug had been mixed with it. I know I made a huge error and I am so thankful it did not harm the patient. But am I wrong in thinking there were other aspects to this as to why the error occured?
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    About brockclan3, LVN

    Joined: Oct '17; Posts: 21; Likes: 76

    49 Comments

  3. by   KrysyRN
    Just to be clear, there was no label on the bag of fluids that indicated Vanco had been added?? It looked like a plain bag of fluids? Yowza. I don't think you are wrong about other aspects. It almost sounds like the RN was interrupted while preparing the IV and pump for you and never got back to setting everything up. I don't understand why a label wasn't put on the bag immediately after the Vanco was added. I can see why an error was made.
  4. by   remotefuse
    You are 100% responsible for this error. You connected the IV and started a medication without checking the bag. There is never a scenario when you don't check a medication before giving it. It takes 2 seconds. It could have been literally anything. You are not owning your mistake if you're saying you are not the only one to blame. You are very lucky your didn't cause any harm, or AKI or anything.
  5. by   remotefuse
    Also, even if the bag wasn't labeled, was the pt ordered a bolus of fluids? If not, still a med error, but you did say you ran a medication wide open without even checking the bag.
  6. by   brockclan3
    Quote from KrysyRN
    Just to be clear, there was no label on the bag of fluids that indicated Vanco had been added?? It looked like a plain bag of fluids? Yowza. I don't think you are wrong about other aspects. It almost sounds like the RN was interrupted while preparing the IV and pump for you and never got back to setting everything up. I don't understand why a label wasn't put on the bag immediately after the Vanco was added. I can see why an error was made.
    No, KrysyRN, there was no label. It looked like a bag of regular fluids. I am a support for the RNs I work with by helping them with their tasks; documentation, giving meds, starting IV's, ect...tech stuff. This creates a whole new aspect for me when it comes to patient care. I thought I was doing the right thing but ended up potentially harming the patient because of it.
  7. by   brockclan3
    Quote from remotefuse
    You are 100% responsible for this error. You connected the IV and started a medication without checking the bag. There is never a scenario when you don't check a medication before giving it. It takes 2 seconds. It could have been literally anything. You are not owning your mistake if you're saying you are not the only one to blame. You are very lucky your didn't cause any harm, or AKI or anything.
    remotefuse, I am not in any way saying I am not responsible for this. I made a huge error and will gladly accept any and all discipline for what I did. I am simply making a point that there were other factors involved.
  8. by   Davey Do
    Quote from brockclan3
    I reattached his IV line and unclamped the line...roughly 5-10 minutes...She told me that it was Vanc and I had just bolused the patient...There was no sticker on the bag of fluids indicating any drug had been mixed with it.
    Pardon me if I seem a little dull, here.

    What was the size of the bag and the IV rate?
  9. by   brockclan3
    The bag was 500ml. I did not know what the IV rate was to be set at. I mistakenly thought the fluids were just basic NS.
  10. by   psu_213
    What is 100% your fault? No. Was it mostly your fault? Probably. Does it really matter exactly what percentage of error was yours? Not really.

    The RN should have labeled the bag, especially if she was going to spike it and leave it at the BS. However, even if it had just been fluids, the potential for an error was still there. Suppose the pt had CHF, so rather than a wide open bolus the doc wanted the fluids to run at 150 mL/hr. It was on a pump before the pt went to radiology, and then while the pt was gone, another nurse stole the pump (I've had pump shortages in every ED in which I've worked). I know this is getting into the game of "what ifs," but it underscores the importance of checking your rights. Sorry if this sounds preachy, but when you are rehooking up an infusion, you are essentially starting administration of the med, and it is always best to go through all your checks--especially if it is not your patient.

    Don't beat yourself up over it--own it, admit to it, and make sure it does not happen again.
  11. by   brockclan3
    No, psu_213, you are not being preachy at all. You are exactly right in what you wrote. I will not make these mistakes again, I can assure you. Thank you for your encouragement.
  12. by   dumbnurse
    Quote from remotefuse
    You are 100% responsible for this error. You connected the IV and started a medication without checking the bag. There is never a scenario when you don't check a medication before giving it. It takes 2 seconds. It could have been literally anything. You are not owning your mistake if you're saying you are not the only one to blame. You are very lucky your didn't cause any harm, or AKI or anything.
    This is the right answer here...end of story...sort of. Med errors happen for many reasons and most often it's not always so black and white. Now that pharmacists are on individual floors, consulting in real time with docs and other providers, we hopefully have more checks in place to reduce the errors. Lack of communication combined with our desire to "get things done", is a recipe for disaster.
  13. by   JKL33
    Not labeling the bag with Vanco was a huge error.

    "Administering" the medication properly (by that I mean verifying 5 rights) might have changed the outcome and it might not have, since 500 ml boluses are a fairly common order in EDs, so that one could've checked a 500 ml NS bag [which, unbeknownst to them included unlabeled Vanco], checked the order to see that there was a 500 ml bolus ordered, had the right patient and all of that. However, had you administered the bag of fluids properly in the legal sense, you would be uninvolved in the erroneous portion of it - that would fall to no one other than the RN who added something to a bag and then didn't label it.

    However, as you have acknowledged, your actions were negligent and it is correct of you to let that sink in a little, as you are doing. You basically hooked someone up to something without completing a legal medication administration. Lots of patients are indeed getting fluid boluses in the ED, but not every patient is. It isn't my intent to rant at you - but the idea of having someone on my team who has been given privileges to hook someone up to an IV but then operates as if "hooking up IV" is a task and not a legal nursing function is frightening and makes me a little edgy. I would think, "Who the H goes into a random room of mine and hooks up an IV solely because they see some of the related equipment near the patient?!" That's basically what you said you did.

    The other thing (which wasn't "the" problem here but will help you in the future) is to communicate. The second there is uncertainty about anything, excellent communication is necessary.

    Okay, this next part is hard. Based on your statement about "just basic NS" and your misunderstanding about legal medication administration - I recommend that you ask your manager for some remediation/extra education about IVs and medication administration. I despise making waves at work, discussing concerns about coworkers, and the like - so I do it very rarely. But based on what you have told us here, if you were my coworker I would pursue with management my belief that your role should change for now (either the amount of independence that you have or the skills that you are allowed to perform or both). Although not doing the 5 rights was the main problem in this one incident, there's a lot more underlying this error than just that.

    You could choose to be proactive about these deficiencies and I think it would be in your best interest to do so. I mean absolutely no ill will when I say that the alternative very well may be a shortened stint in acute care and/or someone getting hurt. So ask for help! Your knowledge of what you're doing in your role is deficient and simply committing to not making this mistake again will not solve the problem.

    Best wishes proactively going forward ~

  14. by   Been there,done that
    The R.N. made the error by not labeling the bag. There was nothing for you to see. I would have done the same thing you did. You already threw yourself under the bus, don't be so quick to do that in the future. The outcome of the incident report should be very interesting.

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