How big of a mistake was this?

[UnidentifiedNurse]

Here is what happened. I had a patient who was having pain issues. He was previously prescribed oxycodone but he said he did not like it and wanted something else. Before my shift today, doctors had already written an order that patient can have vicodin q6h for pain. So when the patient had pain, I gave him vicodin everytime he asked for it whenever he's due. I have a total of 4 vicodins during my shift. What I did not realize though was that the patient was on tylenol around the clock q6h and either the around the clock tylenol or the vicodin should have been stopped. Anyways the mistake was not caught by anybody until the end of the shift after I finished giving report to the oncoming shift. Not even pharmacy. The charge nurse pulled me aside and told me I had made a medication error and a doctor had discovered it. It really did not make me feel good knowing I did not catch this mistake and went on giving the medications during the scheduled time. Anyways my charge nurse told me to write an incident report about the mistake. By the time I was done, she had already left. I had more questions about the mistake and what will become of the patient so I asked the charge nurse for the next shift. She and I went over the patient's medication orders and we calculated how much tylenol the patient was given. During my shift I had given 4 500 mg tylenols and 4 vicodins which contain 500 mg in each pill. This mkes it a total of 4000 mg, which I now know is the max dose a patient can get for tylenol. So then the nurse who took over my patient was told not to give the patient anymore tylenol or vicodins and she paged the doctor to ask what they wanted to do next. I hope the mistake wasn't too big. I know now though to questions orders when both tylenol and vicodin are involved. As of right now, the patient did not show to have been harmed. I don't know though if the doctors wante to monitor his liver function or not though. As I get more experienced though, will it be easier to pick up on these kinds of mistakes before it even gets started?

[EmerNurse, BSN, RN]

You were in a 12 hour shift? How did you give 4 vicodin (Q6 hours?) in 12 hours? Should have been no more than 2. Same with the tylenol. Unless the patient's order was for TWO tylenol Q6 hours and TWO vicodin Q6 hours?

[morte, LPN, LVN]

not trying to encourage you to be lacadaisical (sp) but, dont sweat the small stuff.....i have given much more, (in times gone by) without ill effect....your pharmacy program should have "red flagged" this order as soon as it went in the computor.....and the doc should have d/c the apap when (s)he ordered the Vicodin......since the patient actually only received the recommended upper limit (which, by the way, should only be given for two days) was a med error really committed?...either way, lesson learned, and i bet you wont ever do it again!

of course that 4000 mg upper limit is for nongeriatric patients, for them i think it is only 3000......providing in both cases there are no liver issues.

And i wish that doc worked were i do......i have had a NP insist on givng a patient 2 perc q around the clock.....and apparently got nasty when confronted....

[RNSuzq1, RN]

Hi Anony,

I'm sort of confused - if the order was - Vicodin q6 prn for pain and you gave him 4 during your shift - that would mean you were doing a 24 hour shift???

Not all hospitals do this, but we do chart checks at the beginning of each shift on each of our pt's (before giving any meds). We check the MD orders against the MARS to make sure nothing was overlooked on the previous shift. If the MARS has a mistake on it and you give the meds without checking the orders - it can come back to bite you on the butt. Depending on how horrible the Doc's handwriting is, it can take awhile to do this, but it's a nice safeguard for the pt and you. Hope this helps you out a bit.

[UnidentifiedNurse]

let me clarify. The patient asked for vicodin twice during my 12 hour shift. Once in the morning and once in the afternoon. Each time he said he wanted to take two tablets because he's been having moderate to severe pain. I did not think of it becuase the doctor's order said I can give either one or two tablets depending on the patient's pain level. So in total in my 12 hour shift, gave 4 vicodins. That equals to 2000 mg of tylenol. The patient was also on tylenol around the clock q6. Each tylenol dose is 1000 mg. The dose was due twice during my shift, so in total I gave 2000 mg in 12 hours. So in 12 hours I gave a total of 4000 mg worth of tylenol. Luckily it was caught before the next shift gave any more tylenol or vicodin. I know now to question any future orders like this next time. I know while in nursing school, we had all these tests to calculate whether ordered doses of medications fit within the safe dose ranges. However the ranges have always been provided for us. We never had to memorize them.

[CHATSDALE]

next time have md clarify what the order should be

1 or 2 is not a good order, do they want you to give one or two depending on your evaluation of the pain or do they want you to give one and follow with another before time time specified [ie q6]

i realize the problems is with the amt of apap given but this can happen but it looks worse when the md is the one who catches it take this as a learning experience and keep your med knowledge in mind this mistake may save you and a pt in the future

[UnidentifiedNurse]

it's either one vicodin every 6 hours for mild pain OR 2 tablets every 6 hours for moderate pain. I know if the patient chooses one vicodin, it can't be taken again until 6 hours later. Each time I assess the pain and if the pain med is due, I ask whether the patients want one or two tablets. This patient asks for two each time.

[Chaya, ASN, RN]

These are the kinds of situations where that critical thinking buzzword raises it's head. Where I work the docs will often write "limit 4000 mg APAP Q 24 hrs" as part of the order. If they don't and I notice a potential conflict I might write "see also sched tyl rx" or "see also prn vicodin rx" on the MAR. That being said, sounds like you had a pretty good handle on the basic situation in terms of assessing how much to give according to pain level. I might try to fine-tune it with the pt; giving only one if we catch the pain before it gets bad, or suggesting 2 be given before periods of activity or for overnight. If something stronger is required, I have given PRN vicodin or percocet instead of scheduled tylenol and made a note why I was holding it.

But I think the bottom line here is if this pt was requesting the maximum PRN as often as possible as well as getting the sched tylenol, he was not receiving adequate pain control, and the MD needs to re-assess pain management overall.

[Jolie, BSN]

OK, this question just may show my stupidity and lack of current experience, but here goes...

Since so many facilities use Pyxis and/or bar-code systems for medication administration, wouldn't it be quite simple to program a safeguard into the system that would keep a running total of mg of Tylenol administered in a 24 hour period, or at the very least prompt the nurse to calculate and enter a total prior to administering a dose?

This is the second or third thread in a relatively short period of time discussing over-administration of Tylenol "hidden" in pain medication, so it must be a fairly common mistake.

[Montessori Mommy]

I don't understand how a patient could be receiving Tylenol without you knowing it. Who was administering the Tylenol?

[Nurse Beth, MSN]

It's not uncommon to miss the big picture when you're learning because you have to focus so much on the task at hand- you're mind is all occupied!

Good news is- you will never make that kind of mistake again, and you seem very conscientious.