S. O. S. - page 3

For the first time since I started nursing (I graduated last June) I feel really discouraged with myself. It all started last week. I made a med error. I was waiting and waiting for a now order to... Read More

  1. by   Brownms46
    Dear RNPD,

    Please forgive me for the confusion. When I stated same med, same dosage...I was referring to the Demerol dose. As I stated in my error while reaching for Demerol I picked up the Dilaudid. No where in there did I state Dilaudid 25mg was given by me. I didn't even pay attention to the the dose of Dilaudid Renee said she gave and neither did a couple of other posters, including one who also quoted the post. What I was focusing on was we both gave the Dilaudid for the same Demerol Dose. ...and that we had the same events afterwards. Sorry didn't mean to confuse anyone. In my mind I was focus on the event. For me this happened 21yrs ago, and I was sure I had did the dumbest thing ever. So when I saw Renee post the same Drug error...I was amazed.....and although it was an error that shouldn't have happened...I wasn't the only one who did it.

    You are absolutely correct that there was no way I could give Diluadid 25mg to a pt with one syringe, and I know Renee didn't either, as neither pt. had any adverse effects,.... and as we all know that Diluadid only comes in 1mg/1ml sol./4cc dose syringe. And yes it does come in 4mg tabs, and 3mg supp...but also in 2mg, 8mg tabs and 1mg/5ml syrup.

    But I guess we all miss things...as I also posted:

    "No matter where I go ...I take the med sheet with me to the room and check it against the pt's. ID band so I KNOW I have the right pt. If I'm in a facility where everything is on the pc, I print out a list of the meds for each pt. "-Brownie

    And you posted -RNPD

    "Of course the best way to avoid a med error in this case is not to give the B bed's meds to the person in what you think is the B bed, but rather to check the armband when giving meds to each patient so as to ensure you have the correct patient! "- RNPD

    But making errors, and reading carefully was the whole point of the posts here.

    To you RNPD, and all whom I may have confused...sorry I made the error of not being clear about what I was thinking in my posts.
    Last edit by Brownms46 on Mar 1, '02
  2. by   live4today
    TO RNPD:

    GEEZ! YOU KNOW YOU ARE ABSOLUTELY RIGHT ON THE DOSAGE OF DILAUDID! Thanks for the correction, RNPD! I had to go look it up just now in my PDR, and lo and behold, Dilaudid does only come in 2-4mg tubexes for IM or IV injection! I stand corrected. Thanks again for being on your toes here!

    So, what I gave, and what Brownie46 may have given was Dilaudid 2mgs. in place of the Demerol 25mg IM dose. Why, that's certainly a relief! That could be why the doctor didn't blow my head off! He just smiled at me, and calmly said, "That's okay. She'll just sleep it off, and be no more the wiser."

    Of course that did not make me feel any better! I was so upset with myself the entire day, and I practically gave that elderly patient one-on-one bedside care throughout the rest of my shift, checking her vitals more than I would normally have, and was so relieved when she finally woke up and smiled at me, started chattering her head off (as she was prone to do), and speaking very coherantly with her family who arrived shortly before she woke up. They were never told since no harm was done, but I still wrote up the incident report, and the risk manager talked to me about "the 5-Rs".

    Even though it is a scary thing to make a medication error that could end up costing a patient their life, medication errors are bound to be made. I just thank God that the med errors I was responsible for making did not cause any harm to my patients at that time of learning in my life.

    BTW, the Nurse Manager made a rule that Demerol and Dilaudid could no longer be kept side by side in the med drawer to prevent errors like that in the future. Apparently, a few other nurses told her they had done the same thing I did in mistaking the boxes as the same because they were identical to one another. If nurses weren't so rushed in their work, less errors would occur, don't you think?
    Last edit by live4today on Mar 1, '02
  3. by   Brownms46
    Geeze Renee...I just looked it up too...and found Dilaudid comes in a whole host of different dosages including but not limited to 1mg/ml, 2mg/ml and 4/mg/ml: and a 20ml multi-dose vial

    Thanks for trying to help my mistake not look as bad...but I guess our similarities end here...I gave the whole 4mg! So my screw up was even worse...as you gave the lesser or the usual dose of 2-4mg, and I gave the greater amount!!! I'm just glad that both our pts had no adverse reactions...THANK GOD!!!

    Here's to always being more careful in everything we think, say, do, and post!
  4. by   RNPD
    Thanks to Renee & Brownie for clarifying. Obviously, the lesson to be learned here is to check the med as you remove it, as you prepare it, & as you put the container away, or throw it away.

    Of course we all make errors. My biggest one that I recall was giving Vanco IV instead of the ordered po when i was a new nurse. Had never seen it given off label as po and for some reason read the order 2 or 3 times and saw IV. I guess the mind is a funny thing and sometimes you "see" what your mind expects to see. In spite of numerous warning signs, including the patient telling me he thought the doc had stopped the IV the day before, I still went ahead & gave it. Then I thought to ask the nurse from the day before if she had any trouble giving the pt the vanco & she said, "no just mix it in OJ". Talk about your heart sinking! Well no real harm done, the pt was getting it iv until the day before and so missed one oral dose. But that scared me enough because it COULD have had serious consequences. I refuse to hurry thru meds anymore.
  5. by   RNPD
    Forgot to ask Brownie-the 20ml vial of morphine-how many mg/ml does it hold? Never saw one and would imagine them to be VERY dangerous as opposed to unit dose-not to mention easy to tamper with. Also never saw an 8 mg po dose-is it new?

    Also, when I said it comes up to 4 mg IV and po, I didn't mean to imply it was the only dosage. We carry 1mg/ml & 2mg/ml IM/IV or 1mg and 2 mg tabs. I personally have never seen any other dose and was going by my drug book. It didn't mention multidose vials there, but it is an OLD book! I need a new one!
    Last edit by RNPD on Mar 1, '02
  6. by   live4today
    RNPD, in my new PDR, it does mention a 20ml multidose vial of Dilaudid. Thanks for your reply!

    Brownie, we would have both caught that one and known it would have been too much! We would have, wouldn't we? Of course, let's not even entertain that thought! Now, that would have landed us both behind bars had we given that much dilaudid! We might be cell mates, eh?

    We can make light of our mistakes, but the serious nature of making serious medication errors is certainly Never to be taken lightly! And, I never would, and never have!


    "Good judgment comes from experience, and often experience comes from bad judgment." -- Ashleigh Brilliant
    Last edit by live4today on Mar 1, '02
  7. by   RN-PA
    I made a stupid-- no excuses --med error in the last year involving insulin. The patient was a post-op and I was rushing around during a typically hectic evening. I unfortunately read the patient's insulin order off of the med kardex (rather than from the chart-- I know. I know.) which had been sloppily copied by a Unit Clerk notorious for bad handwriting. (I know. I know. More reason to double-check.) I read "Insulin, 40 units 70/30, SQ q p.m." and administered it after doing a fingerstick to check her blood sugar and after she'd eaten dinner. Problem was, the order was for "Insulin, 4 units 70/30 SQ". On the kardex, it appeared as, "Insulin, 4u 70/30 SQ" with the "u" looking like a "0". .. and I saw "40".

    The House Doctor was called, came up and wrote orders for stat D50 and asked to see the kardex with the order. He said, "What's the problem? It says Insulin 40 units 70/30 here." I showed him the order in the chart and he proceeded to reassure me like crazy that anyone would've read that wrong. The attending M.D. was contacted and also reassured me, "We all make mistakes" and was very kind, but nevertheless, I was beating myself up and deserved any stern rebuke they could've given me; I wrote the incident up, and the poor patient had to endure q1h Accuchecks through the night due to my mistake.

    Yes, I learned a hard lesson that I pray I won't ever repeat, but we are all human and make errors at times. It can be dangerous when things get so chaotic and busy, but it's vitally important to stay focused and calm in the midst of the storm. Some nights I'm amazed that MORE mistakes aren't made... :imbar :stone :imbar My husband has said, "You can't be perfect-- Nobody is!" But my response is always the same: "This is one job where you pretty much HAVE to be perfect." :stone
  8. by   Brownms46
    Dear RNPD...,

    Yep...your drug book must be an OLD one..lol...because the multi-dose is 2mg/20ml!! Now with that we could have given 25mg!!!!!! and liq can come in as much as 10mg/ml. Also tabs come in 1mg, 2mg, 3mg, 4mg, and 8mg. Powder for injection can come in a 250mg/vial!!! Geeze would have hated to have got hold of that bugger!!!! Lordy

    Geeze aren't we lucky...they didn't have all this stuff in that old med cart!! WWHEEEWWW!
    Last edit by Brownms46 on Mar 1, '02
  9. by   mattsmom81
    I think the public must be made aware of the fact that med errors are increasing with poor staffing ratios and insufficient internships/supervision of new grads. Hospitals should be held accountable for their poor staffing practices. Hospitals are trying to hide that fact behind a smokescreen..they say "Oh, nurses have always made mistakes, they just covered them up for years and now they're documenting more." I've caught some doozies of med errors in the past few years where I have been fortunate to prevent the deaths of patients...only my years of experience prevented tragedy. We must be scrupulous with meds. And yes, we all make mistakes (being the humans we are) but we must never let this issue become blase. Unfortunately I have worked with those who do...and the mistakes continue. We have to be hard on ourselves and learn from our mistakes. I'll get off my soapbox now!
  10. by   Brownms46


    As I was responding to RNPD...I was thinking...GOD if we had given that much...we would have been on the news...and in jail.. !!!

    All I can say is Thank you Lord...for saving our PTS. FIRST...and OUR NECKS SECOND!!:imbar :imbar
  11. by   live4today
    Hi Brownms46! Our similarities are too surreal to be true, aren't they? Mindblowing, indeed! :chuckle

    Hi mattsmom81! You couldn't be more right in saying nurses need to slow it down, and take the time to be more accurate, especially in light of how "busy" nurses are today with the way they are working under such stressful conditions. Here I am trying to return to nursing after a five year sabbatical, and I'm concerned about re-entering under the present conditions myself.
    I've had such a wonderful experience in nursing in prior years, and I would hate to ruin that beautiful memory by returning only to face a much more stressed environment than ever.

    We all need to pray for health care to change for the "BEST", not just the "better".

    I am sooooooo "anti-HMO" that I wish Prez Bush would do something with them. They have far too much control over our health care system. It's making me think that our health care system has been turned over into the hands of 'COMMUNIST' to manage!

    How do some of you view HMOs today and how they are affecting patient healthcare? Or, is that another thread???
  12. by   Brownms46
    One other thing Renee....as to your question about whether I would have noticed the different. I'm sorry to say I probably wouldn't have on that evening I made the error. I wasn't looking! I looked in the cart and saw the box of Demerol, but reached in and got the Diluadid instead! This happened...one year after graduating. The day after I finished school.... I started in NICU....and crossed trained in L&D. One year later went to a med-surg floor as agency, after not having set foot on a M/S floor since clinicals....and this is when I made the error.


    Yes...I noticed in your post that you stated up to 4mg/ml...after I went back to read over what I had posted. Also...sometimes different med books will shortened and only print what is the usual info used/needed. Sometimes you can only find out the full info on a med by reading the drug inserts from the boxes. Everytime I see a new med in a box...I always try and get a copy of the it. There have been many times I have had to call a Pharmacist...and have him pull the insert and read it to me...because we couldn't find the med in even the newest PDR!

    You know...so many times...I look at what I wrote, and have to edit numerous times...even after I try and read it over before I press the "submit" button. I'm always amazed at what I thought I wrote, and what is actually posted. It's difficult to relay your thoughts to print, at least for me it is.

    You're are so very right about...Our minds seeing what they are expecting to see.


    I'm so very sorry to hear about your experience. For some reason... tears started coming to my eyes as you related the pt. having to endure the q1hr Accucks. I know this must have been a test of endurance for you also. I guess I'm still also thinking what could have happened with my own error.

    I hope and pray that what we have related here will help another new or old nurse to not repeat our mistakes.

    Fran-RN...I would have totally freaked also.but good save on that
    one! WheeW!!
    I'm going to go outside and get some fresh air!

    Last edit by Brownms46 on Mar 1, '02
  13. by   RN-PA
    Brownms, I was terribly upset about my med error but more upset by the q1h Accuchecks. (We need an emoticon with tears flying out of its little blue face...)

    Not that I'd want this to happen to ANY patient, but this Insulin error happened to a patient who I had grown to love during her previous admission and who, along with her family, also loved me. She told me I looked like Julie Andrews (you'd have to squint to see any resemblance, IMHO) and so when I'd give her meds, I'd sing "Just a spoonful of sugar..." and sing snippets of other songs from Mary Poppins or Sound of Music. When she saw me for the first time during that post-op admission, she yelled, "JULIEEEE!" and reached up from her bed to hug and kiss me. I can hardly convey how really badly I felt that night after my error... *sigh*