What would you have done?

[aurora_borealis]

A co-worker was caring for 2 patients who were being treated with the same drug (cytoxin) but one of the doses was twice the amount of the other. She started both infusions within minutes of each other. About halfway through the infusions she realized she had mixed up the doses, so that patient A was receiving twice the ordered dosage, while patient B was getting about half the dose. She immediately told the physician what happened, and his resolution of the mistake was to stop the infusion on patient A and infuse the remaining amount into patient B. No, I am not kidding. I'm not sure which stunned me more, his idiocy or my co-worker who didn't bat an eye and actually started to do what he told her to do. WTF????? I went ballistic and told the doc no way, no how, was this going to happen under my watch. After 5 minutes of screaming at each other he finally walked away in a huff, mumbling that I could do whatever I wanted. Just as well, because I was ready to call in the calvary and I think he knew it.

How would you have resolved this?

[caroladybelle, BSN, RN]

Cytoxan is a chemo drug.

What hospital these days, doesn't require double checks (two nurses) at the bedside for a chemo check?

JCAHO would have a field day.

[BittyBabyGrower, MSN, RN]

That would be an incident report in my book...the 5 R's weren't checked. What if that were some other type of drug and one happened to be double concentrated (as some of our drips are)..that is one big boo-boo.

And I'd make darn sure there were written orders in my chart to back up what I did...meaning, stopping the infusion on one and continuing on the other.

[Agnus]

No one mentioned bringing in pharmacy into this equation.

I do not know if we are talking about taking a spiked bag from one patient and giving it to another (a no no), or if you mean the one patient had 2 bags and one had only one and they were all the same concentration and there was one bag not yet spiked (doesn't sound like the latter was the case)

In any case. I would involve pharmacy to calculate the dosing and to re-issue new bags. I understand this is an expensive drug. NO DRUG IS SO EXPENSIVE THAT IT IS WORTH CUTTING CORNERS WITH PATIENT SAFETY. A mistake was made there is not reason the patients should pay for it with thier safty. A human mistake but one the hospital should assume responsibility for and re-dispense if necessary.

Get pharm involved this is thier area of expertise and is yet another set of eyes when it comes to figuring these things out.

[aurora_borealis]

I'll clarify: The nurse mixed up the patients and the doses, and the MD told her to stop the infusion on the patient who'd been receiving the double the prescribed amount, and yes, take the bag and infuse the remaining amount into the other patient, meaning switch the bag that had been given to patient A and give the rest to patient B. I did not "eat our young." The RN involved had more experience than I in that setting, it was just that I'm much more assertive and don't assume that whatever the MD says is necessarily right. I believe that nurses HAVE to be patient advocates, and to blindly follow a physician's order is not only stupid and a set up for a lawsuit, but unethical and immoral. This is what I ended up doing....I called the infectious disease nurse on call just to validate that I wasn't crazy, I called the supervisor for the hospital (it was a weekend) and finally, the pharmacist, where we worked out that the patient who still needed about half the dose would get a new bag, based solely on "guestimations", because it was impossible to judge just how much of the drug has actually infused. I had complete support from everyone involved, and nobody told me to do what the doctor ordered. Remember the doctor walked out in a snit and told me to handle it any way that I saw fit, so I did. He was notoriously difficult to deal with, which is why I think my co-worker didn't challenge him, and frankly I didn't want to either, especially since I wasn't even caring for these patients. But you do what you gotta do in order to sleep at night.

[SCRN1]

I think you did the right thing.

Back to what someone else stated...do you not have to have 2 nurses to check before chemo is given?

Does your pharmacy not label each bag with the patient's name, room #, etc., or did she confuse that?

(Just trying to get a better idea on how she got mixed up. I know it happens & I'm always trying to find ways from preventing that.)

[loerith]

I'll clarify: The nurse mixed up the patients and the doses, and the MD told her to stop the infusion on the patient who'd been receiving the double the prescribed amount, and yes, take the bag and infuse the remaining amount into the other patient, meaning switch the bag that had been given to patient A and give the rest to patient B. I did not "eat our young." The RN involved had more experience than I in that setting, it was just that I'm much more assertive and don't assume that whatever the MD says is necessarily right. I believe that nurses HAVE to be patient advocates, and to blindly follow a physician's order is not only stupid and a set up for a lawsuit, but unethical and immoral. This is what I ended up doing....I called the infectious disease nurse on call just to validate that I wasn't crazy, I called the supervisor for the hospital (it was a weekend) and finally, the pharmacist, where we worked out that the patient who still needed about half the dose would get a new bag, based solely on "guestimations", because it was impossible to judge just how much of the drug has actually infused. I had complete support from everyone involved, and nobody told me to do what the doctor ordered. Remember the doctor walked out in a snit and told me to handle it any way that I saw fit, so I did. He was notoriously difficult to deal with, which is why I think my co-worker didn't challenge him, and frankly I didn't want to either, especially since I wasn't even caring for these patients. But you do what you gotta do in order to sleep at night.

Switch bags??? WTF moment is right! My apologies I misunderstood and I do think you did the right thing. I still stand by my statement though that nurses in general are quite divisive.....and well basically "they eat their young".

:rotfl:

Love and Peace,

loerith

[pghfoxfan]

I would never have taken the one bag down and givin it to another patient. I miss understood your first post. And I also, stand by my comment that nurses eat their young.

[sleepless in norman]

Read my story entitled " Down and Dirty in the Oklahoma State Board of Nursing" on this Forum, by me sleepless in Norman.

OK...I totally missed it where she said that someone switched bags? I am NOT talking cross contamination here! That is a total WTF moment! I am saying if the nurse took down the ones bag and continued the other persons bag. And I agree, Nurses out # doctors and almost any other profession. If we stuck together, look and see how many good things we could do together. Look at the people we could vote into office. Nurses need to UNITE!

[nycegyrl]

I Commend nurses for staying in the hospital setting when there is such a nursing crisis and the work is so difficult. All too many nurses are taking these "phone insurance" type jobs, or jobs that take them out of the patient care setting for that perfect M-F daylight job, leaving hospital nurses critically understaffed and over worked. We should be saying Thank God you still want to work in a hospital setting, and cut them a break if a error happens (that does not harm the patient).

If we had enough nurses to go around, and we weren't so busy doing JCAHO paperwork ****, we could give the patient care that we were taught.

In your honest opinion would hospitals staff more nurses on the floor if they were available or would they keep the numbers they are currently using because they are getting the job done? More cost effective.

:chair: