giving med to patient with allergy...

MegNeoNurse · Dec 19, 2007

I'm sorry this happened to you, it's always the worst wondering what to expect the next time you get to work. And yes, it's unfortunate, that even though the docs write for something which is not safe for a patient, we are still required to catch it. But that's part of nursing, part of being a patient advocate. Also, we know to check all the 5 rights before admin., which that patient should have had an allergy bracelet on.

I assume that you completed an incident report as this was a med error that potentially put a patient in danger. I don't know truly what to expect as far as your institution goes as all policies and procedures vary. Perhaps that's something you can review. Did you talk to your charge nurse about it? Manager spoke to you?

Once again I'm so sorry that this happened. I wish you the best of luck today

Thunderwolf, MSN, RN · Dec 19, 2007

This scenario and the pt (lack of allergic) response afterword is something that I would like to comment on. Many a times in the hospital (psych and non-psych), patients may say they have "an allergy" to a particular medication...when the case may be more accurately described only as not liking a particular side effect (not allergy...or allergic response). You see this all the time with Penicillin or something else. Many folks, especially Manics or Schizophrenics, may say that they are "allergic" to a med...when actually sedation or akathisia or nausea or weight gain or et cetera are only something they are truly wishing to avoid experiencing again....although side effects, they are not allergic reactions. So, if time allows, it really pays off beforehand to explore what side effect or "allergic response" did or did not occur with what med, and when in what situation, and if other meds were involved around the same time. If a med is listed as an allergy and if it truly is not after additional investigating, the patient record really needs to reflect the more recent and accurate information.

You did the right thing by closely monitoring the patient afterward...the prudent thing to do after needing to medicate a person with mania. Keeping the doctor informed is important, as well as documenting the actual patient response afterward. I would say an honest mistake...for these meds that you gave are very commonly used. An incident report is warranted because it is a med error....however, I would also document that NO allergic response was noted as evidenced by:______________.

You're OK. And a valuable experience for yourself.

Again....when meds are taken, these are the scenarios:

1. Normal/expected response: the reduction of particular symptoms...the reason the med is given

2. Side Effect(s): all meds have them (increases with the higher the dose +/or the longer the duration)...fairly predictable

3. Allergic reactions: not usually expected, but could occur...a physiologic histamine reaction

4. Adverse reactions: not normally expected, but "have occured" to an individual...with the

potential of causing/had actually caused pain, suffering, damage, or death

Thanks for the post.

elkpark · Dec 20, 2007

I'm not trying to jump on you after the fact, but I have two larger problems with what you've described here. First, you medicated someone against her/his will, while the person was actively refusing the medication (and not, according to your description here, acutely dangerous to herself or others). I don't know what state you're in, but that would be a v. serious violation of state mental health law in my state, and could leave you open to criminal charges if the client chose to press them (in my state, I mean -- I don't know what the law is in your state). It's well worth familiarizing yourself with what your state laws are regarding forcing medications on people.

Also, your description of holding down her down to administer the injection is a violation of the CMS (Federal) rules regarding restraint/seclusion, and, probably, also your state laws regarding restraint & seclusion, unless you got a physician's order for the restraint and went through the whole business of getting the face-to-face eval done within one hour, etc. I worked as a psych surveyor for my state and CMS for a number of years, and can tell you that CMS intends that even something as "minor" (which it isn't, really) as holding someone down for an injection be treated as a "full-fledged" restraint. We cited hospitals for that all the time.

Thanks for bringing up this topic -- there is a lot of confusion on psych units about what can and can't be done to people against their will, and what does and doesn't need to be treated as restraint or seclusion.

PsychNurseWannaBe, BSN, RN · Dec 20, 2007

Well... I have several things.

1. Along the same lines as Wolfie, many times I hear that someone has an allergy and it really isn't a true one... My question is this... if the patient history from the other hospital listed an allergy to Ativan, was it witnessed or really is it just another patient history from a third place. My point is if the patient states that they have an allergy and they are given that med and nothing happens because they are truly not allergic, why do you have to fill out an incident report?

2. Regarding giving meds against their will. Mania in itself is considered a medical emergency regardless of threat to self or others. What I mean is, a person who is manic really can "run themselves to death" and even if they are not violent, they still may need to be medicated. I am hoping the person got an order... but if they have a PRN order than they really don't need to get more orders. (At least at our state facilities)

3. Providing a chemical restraint is a restraint and I would also suggest as the OP stated to become familiar with laws and policies. At our facility the RN can initate a seclusion or restraint provided by a phone call to the MD as soon as possible, but a face to face is not required until 4 hours have past. The order can be written for 2 hours and renewed once (2 hours) = the 4 hours.

allnurses Guide · Dec 20, 2007

Well... I have several things.
1. Along the same lines as Wolfie, many times I hear that someone has an allergy and it really isn't a true one... My question is this... if the patient history from the other hospital listed an allergy to Ativan, was it witnessed or really is it just another patient history from a third place. My point is if the patient states that they have an allergy and they are given that med and nothing happens because they are truly not allergic, why do you have to fill out an incident report?

It is a med error because the nurse didn't check for allergies - regardless of whether a patient is truly allergic or not - we MUST check for allergies prior to medicating.

As to whether THIS time there was no allergic reaction - that isn't completely the answer to whether they are allergic or not.

steph

MegNeoNurse · Dec 20, 2007

What I have a problem with here, is if a patient states they have an allergy to a medication, who is to tell them "no you don't"? And then admin the med they stated they have an allergy to anyway? I understand that these are psychiatric patients, but I would think that something like a med allergy is something you would take someone's word for? I know there are almost always alternative medications to medication that someone is allergic to.......

Thunderwolf, MSN, RN · Dec 21, 2007

the doctor had ordered ativan 0.5 mg and haldol 1 mg, which i think is actually a small dose as this woman is pushing 300lbs. so i went down to the room with the needle, she got even more upset and combative, there was no reasoning with her at all. men got on both sides of her, held her, i administered. she was still going on and on and on and finally asked what we gave her and we said ativan and haldol, which made her start up more. she started saying 'you can't give me ativan, i have an allergy' etc etc. we got it out of her that she gets a rash from the ativan.

csm08mms, i hear your concern and agree with you. but, the course of the events were as such (as written above): med was administered first...then patient asked afterward what was given....not the other way around. if the patient had asked prior to administration what the med(s) were and stated an allergy, the nurse would have been in great error if he/she then administered them after being informed. but, this was not the case in this scenario.

Thunderwolf, MSN, RN · Dec 21, 2007

It is a med error....because "current documentation" in patient chart lists Ativan as an allergy....regardless if it is a true allergy or not. Again, it pays to explore patient allergies thoroughly upon intake/admission with the patient (and if possible, with a family member). I consider intake as part of the educational process with patients regarding their meds....to know their meds (name, dose, frequency), why they take them, compliance issues, if any side effects, the presence of any allergies and what allergic responses presented for them, to discuss the difference between allergies and side effects (not the same), et cetera. Intake is an invaluable process...for both the nurse and the patient. It is here that incorrect information regarding meds can be corrected, making the chart reflect more current and more accurate information. Again, in this thread scenario, it was a med error....for there was no "additional chart documentation" to indicate that the Ativan was NOT a med allergy prior to its being given.

So, in this case, the chart currently reflects allergy, med was given...med error.

PsychNurseWannaBe, BSN, RN · Dec 21, 2007

OK...now what happens since the patient did not have a reaction. Does the chart reflect that? Does the allergy stand?

Additional:

Can she now be given the med since she did not have any adverse/allergic reactions or would you still consider her allergic just for safety sake?

Thanks all... great discussion

lpnmeg · Dec 21, 2007

Wow, you guys took this scenario to a whole new level! I don't know where you got the idea that we violently held the patient down and stuffed her full of something she said she was allergic to. The statement came after the fact, because there was no getting it out of her beforehand. We didn't even get a chance to do a proper chart check because she was hell on wheels from the time she reached the floor. The doctor said the next day when the rn spoke to him that yes, he saw it in the chart but felt the ativan would calm the patient and a rash is more easily dealt with that an out of control patient. I appreciate all of the input, except the input insinuating that i am a negligent nurse who did everything possible wrong. She's doing beautifully now by the way, and she still gets the ativan with no problems and is thankful for all we are doing for her.

PsychNurseWannaBe, BSN, RN · Dec 22, 2007

LPNMEG,

Glad to hear that everything is working out and that the client is doing better. I appreciate you sharing your day... Have a great weekend!!