yesterday there was a huge med error made on my unit. i didn't make the error; in fact i was the person who caught it. my patient almost died during my shift. i had last night off, so i don't even know if the patient did die after all.
i feel so sick. i haven't been able to sleep. i'm terrified of going to work. i feel almost as if i had made the error. i keep reliving the moment when i checked the iv pump and realized that it had been programmed incorrectly. i just keep thinking that it could just as easily have been me who made an error like that. have i always been as vigilant as a could be? have there been times when i merely glanced at the pump settings during a double check?
i am shaking so badly that i don't know if i can work. also, i do not want to be grilled for information on what happened by my co-workers, although i really need someone to talk to. i tried to tell my family what happened, but they really can't comprehend the situation well enough to understand my distress.
i really like the nurse who made the error, and i am frightened for what will happen to her. on the other hand i am also resentful of her (and of the other two nurses who were supposed to have double-checked the med) for throwing me into the mess i had to deal with last night. i had to watch the patient's wife crying at the bedside. i kept thinking, "i hope she doesn't think it was me who did this to her husband." but then i also thought that i am absolutly capable of making a similar mistake, so why shouldn't she think it was me. haven't i just been lucky?
Usually heparin is running at between 10 and 30 ml/hr, depending on the weight of the pt and the concentration of the solution, plus their individual physiological response. If I saw 80 ml/hr I would KNOW something was wrong!!!
This is a good reminder to us all to double check our critical drips when we come on. To the OP, good catch!
I like the new pumps where you can program in the particular med, and it gives both units/hour and ml/hr, plus the name of the med.
Specializes in Community Health, Med-Surg, Home Health.
Things happen. My facility (allegedly) says that there is no punitive action most of the time, because nurses do not come to work with the intention of making mistakes, and that sometimes, there are systematic problems, such as an overload of patients, too many distractions and other things to contribute to errors. Of course it does not make us feel any better. And, for sure, it could have been me, because I don't hang heparin often...in fact, I have never hung it at all, only administered sub-q injections.
What you can think of, though is how sharing this story has helped numerous readers on this site. Now, when I work med-surg per diem, and I have to hang heparin, I will remember that it should be low doses for the hour, and I will check and double check until I know I am correct. What I have seen happen (highly unfortunate), is that many times, rules are that heparin, insulin and potassium (amongest other high alert medications) should be double checked, when, many times, it is not. That makes me highly uncomfortable, because we have a computerized system, where as we document, we are supposed to put down what nurse witnessed the calculation. I have seen nurses type in anyone's name, without their knowledge. That, to me is worse, because you can be pulled to court behind things you have no knowledge of. I really believe that both nurses should apply their access code as proof that it was actually checked-this forces people to do the right thing, and maybe this could have been discovered. I pray for the patient as well as the nurse.
I have seen nurses type in anyone's name, without their knowledge. That, to me is worse, because you can be pulled to court behind things you have no knowledge of. I really believe that both nurses should apply their access code as proof that it was actually checked-this forces people to do the right thing, and maybe this could have been discovered.
Worked with both systems, and people aren't much more likely to check before putting in their code than the other system. Basically it comes down to a nurse MAKING someone actually double check them.
Good feedback from all of the above. To the OP: perhaps the best way to deal with your upset over this issue (in addition to EAP) would be to volunteer to look into the system of checks and see if there is an additional safeguard which could be added to prevent recurrence, since as said above, most med errors involve some sort of breakdown in the system.
Use this as a learning experience to remind you to always check what you hang, pour, program, etc... I've seen people do careless things (hang levaquin instead of levophed, titrate insulin instead of vassopressin) and realized like you did that I'm not above such mistakes either. Take the extra second to read the label and think about what you're doing. After all, it's important stuff you're doing! :wink2:
I am always so careful when it comes to heparin drips, you can never check too many times. On a side note, related to heparin drips though, I need a second opinion. I was taking care of this LOL who has been on a heparin drip, Hx of DVTs, admit for PE, and they can't seem to get her PTT to stay within her assigned therapeutic range. Well this morning, the aide was helping this patient wash up (she was in B bed) and I was with pt in bed A. All of a sudden I saw the aide walking this woman to the bathroom and he had disconnected her heparin drip to do so. While she would only be in there a few minutes, I told him to absolutely not disconnect her from this medication. Not only that, but he did not cap the end of the tubing which would allow potential bacteria to get in. Was I too harsh in telling him to never disconnect the patient without my permission (from a heparin drip, regular fluid maintenence is different) or did I over react? I'm just so crazy when it comes to heparin drips, especially given this patients Hx and current situation.
I tell you, every time I hear of a med error like this all I can think is, "Thank god it wasn't me." I am very careful and we do double checks and all, but mistakes happen.
I go home after evening shift and lie awake thinking about things I may have done wrong...and I'm a 15 year veteran. I swear this job will be the death of me.
The great thing about heparin is its crazy short half life. You can turn it off for a few hours and the patient's ptt will normalize.
I have seen a patient get a 10x overdose of heparin with no negative outcome.
The woman who died of spinal hematomas had an allergy to heparin, as in her it induced thrombocytopenia. Unless someone has that problem, once they have survived the first few hours after the heparin drip has been stopped or decreased without negative consequences, they can probably be expected to have no further risk of adverse effects from the event.
We really do have to take what we do seriously. We are putting very potent substances inside other people, and errors can have life-altering or even fatal consequences. And yet, we cannot help but be human. Do your best to check yourself, but never be afraid to have someone else check you. And if you check another person's work, really be critical and expect to find an error every time. Most people see what they expect to see, so if you are expecting to find errors, you will be less likely to miss them than if you just nod your head and agree without really examining what you are looking at.
FireStarterRN, BSN, RN
3,824 Posts
Usually heparin is running at between 10 and 30 ml/hr, depending on the weight of the pt and the concentration of the solution, plus their individual physiological response. If I saw 80 ml/hr I would KNOW something was wrong!!!
This is a good reminder to us all to double check our critical drips when we come on. To the OP, good catch!
I like the new pumps where you can program in the particular med, and it gives both units/hour and ml/hr, plus the name of the med.