Would you classify this as a med error? I think it is. - page 2
Went for kidney scan yesterday. They put a IV in me and handed me contrast to drink. I drank it dutifully. When I walked into the cat scan room the tech was like "OH OH". I was supposed to have... Read More
Aug 7, '02Occupation: RN Joined: Nov '99; Posts: 2,950; Likes: 619Incident report my foot. I would insist that it be documented on my chart. The incident report is designed to protect the hospital. This needs to be documented on your medical record. An incident report is only admissable in court if the suing attorney can discover that it exist. Otherwise it is the hospial's own confidential record.
Documenting it on your chart is the only thing that protects you the patient. Supose you were harmed. Or supose something occured later as a result of this incident. Like lets say an allergic reaction to a later use of contrast. This should be in your record. Incident reports never appear in a patient record.
Aug 7, '02Occupation: Nurse Educator: love those students! Specialty: Med/Surg,ER,L&D,ICU,OR,nrs. educator ; Joined: Apr '02; Posts: 968; Likes: 41Are X-ray techs held to the same standards in med passing that we are? Any x-ray techs out there?
Yes, it would be a med error if done by our nursing staff.
Aug 7, '02Occupation: RN Case Manager, Hospice Specialty: 15 year(s) of experience in Hospice, ER, telemetry ; Joined: Apr '02; Posts: 161; Likes: 1Originally posted by oramar
Went for kidney scan yesterday. They put a IV in me and handed me contrast to drink. I drank it dutifully. When I walked into the cat scan room the tech was like "OH OH". I was supposed to have injected dye. So they gave me two options. Stay there and drink water in attempt to flush it out of my system. Or reschedule at later date. I rescheduled. I have seen to many situations as a med/surg nurse where that contrast just would not flush. I did not want to spend 3 or 4 hours only to find that they could not get scan anyway. I am glad I did not say I am a nurse. I would have looked dumb for not knowing mistake being made.
As an RN working in the radiology department, I can tell you that it is routine to do abdomen and pelvis CT scans with po/iv contrast unless otherwise ordered by the physician. The po contrast enhances the stomach and intestines, which are visible in pelvis scans and the IV contrast enhances the liver, kidneys, and bladder. Yes, you should have had both forms of contrast.
Aug 7, '02Occupation: returned nurse Joined: Nov '98; Posts: 7,097; Likes: 5,234This is very specialized sort of scan that the doctor did not want the first kind of contrast to be drunk. I admit I am not to up on what goes on in radiology. I was told there was deffinitely a mistake and the tech recoginized it as soon as she saw the actually order. She was on the phone with the doctor in minutes. HE wanted a CT that actually looks like a angiogram of kidney arteries. Apparently, the stuff I drank would obscure the picture.
Aug 7, '02Joined: Dec '00; Posts: 830; Likes: 64Yes that is a medication error, in no uncertain terms is it not, it is also a delay in a scheduled test, and a cost delay to you and a time delay for your physican. There should be a incident report made, and I would expect that your Dr to know as well. Isnt the xray department under the same 5 rights conditons as the rest of the hospital?
Aug 7, '02Occupation: Special Populations Paraeducator Joined: Jun '02; Posts: 166; Likes: 6Med. error! Get copy of incident report and witness this incident documented in your chart (get copy of that too)for any further discussion or litigation down the road.
Aug 7, '02Occupation: R.N. Specialty: 27 year(s) of experience in cardiac, diabetes, OB/GYN ; Joined: Feb '02; Posts: 1,947; Likes: 418Definitely. AND, I am getting pretty tired of every other department but nursing having no answers or consequences for their mistakes. All an incident report does is report an incident. Perhaps the mention of same might light a meager fire, however a call to the manager of the department with the information that your lawyer suggested you follow up on it, might light a warmer one.
If you aren't interested in making a fuss, they won't be interested in changing their policies , lines of communication or correcting their mistakes. It doesn't seem as though it was a big deal to them. From the way you described it , they were more worried about you finding out they made a mistake than admitting their error and possible consequences to you..Good luck to you...Might not hurt to pen a letter innocently asking if all departments of the facility are equally culpable when an error is committed, to the CEO of the hospital. They are always interested in good patient relations, and a letter might get passed via memo to the erring department and keep them on their toes for future reference...
Aug 7, '02Joined: Oct '00; Posts: 8,729; Likes: 8,412For heavens sake it was a mistake! THey recognized it and did their best to correct it and I would assume that someone apologized. It didn't hurt anyone, just a big inconvienence. Why would anyone sue? It's too bad that is the first thing that comes to everyone's mind, we are all human and eventually we will all make a mistake just as stupid and inconvienent.
Don't think I am belittling the experience you had oramar, it was a big mistake, but everyone survived. In my opinion lawsuits, letters, demanding your chart would be over the top. Asking that they double check themselves before you accepted the next prep would be appropriate, as would a nastygram if they charge you for the botched visit.
Aug 7, '02Occupation: Nurse Educator, NP Joined: Jul '02; Posts: 26; Likes: 1YOU GO GIRL!!!!! We are all behind you, because you have been doing something to protect your rights. I hope everything comes out well for you. Keep the faith, especially in yourself! joenp
Aug 7, '02Occupation: Acute Rehab Nurse Joined: Apr '02; Posts: 311; Likes: 1Hummmmmmm........can we all say........CALL YOUR ATTORNEY?????
OMG.... miscommunication????? I guess so. Did you have any adverse effects?????? Did you find out about any 'lasting' problems????? I'm hoping and praying all if ok and you don't suffer any ill-effects, but I would contact my attorney. This could have been a potiential serious situation!
Aug 8, '02Occupation: RN/Risk Management Joined: May '02; Posts: 130; Likes: 2An incident report should be done which would probably result in a RCA (root cause analysis) being done to find the root cause of the system or process problem or break down in communications.
Aug 8, '02Occupation: returned nurse Joined: Nov '98; Posts: 7,097; Likes: 5,234Thank you very much to all the persons who agreed with me that it was a medication error. That was actually my question. As for what I did afterwards I am perfectly comfortable with the steps I took. Don't need anyone to say I should have done this or that. The tech wanted to hustle me out of there without addressing it. Seemed to think it was not a real drug error. I begged to differ and insisted on asking a few questions and getting a few answers. Need to make sure steps taken to make sure it did not happen again. Not interested in make big fuss like calling lawyer or anything. Not necessary, no harm permanant harm done. Inconvience yes, if they had to inconvience someone let it be me cause I actually have the time to come in and do it over.
Aug 8, '02Occupation: RN Specialty: correctional, psych, ICU, CCU, ER ; Joined: Jun '02; Posts: 620; Likes: 85Why should you feel embarrassed? They screwed up. What were we taught in nursing school?? (This is where everybody jumps in)
They didn't follow the things beginning student nurses are taught about medication administration. Yes, it's a med error.