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I think I made a med error with an antibiotic and didn't realize??

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by jeddyl jeddyl (New) New

559 Profile Views; 6 Posts

I am a new nurse, I've been on my own for about two maybe almost three months. I work on a med/surg floor and I thought I was starting to get the hang of things (sometimes). Lately I've been a little disheartened- I had a charge nurse stop me before I left about a week ago to talk to me about a medication from a week prior..I had a patient with Phenergan 25mg ordered. The first night I could have sworn it was to be given IV so I diluted it in NS labeled the bag and hung it. No harm. The next night in report I was told she had IM Phenergan 25mg, so I made sure to give it that route- I thought the doctor changed the order, but am not so sure because it had been a while. Anyway the charge approached me because of the IV route from the one day and also because of the dose- I didn't know we couldn't give 25mg IV although that was the order. This was my first mistake.

Now, I worked last night and got a phone call from a nurse who works with the new hires to check up on them during and after orientation. She wants me to come in and meet with her and my nurse manager because of something I did with an antibiotic. She said the patient was fine and not to worry- but thats all the detail she gave me. I know I hung IV Vanco last night. But thats the only thing I can think of. Everything was scanned, and I can't imagine what I may have done wrong? I am so nervous. And they want to know my reasoning and thought process.... I know I hung it was a 500ml bag of normal saline incase it was burning while going in (the patient was 80).

Unless I made an error more than one shift ago?

Anyway I don't know what I'm going to say, and unsure of the situation thus far, and am so so nervous I'm shaking.

Any thoughts or advice???

Thank you!

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65 Posts; 3,628 Profile Views

Did you read the order to see how the doctor ordered the Phenergan be given? As far as the vanco, did you dilute it in at least 250 cc of NS and then piggy back it onto 500 cc normal saline? I'm a bit confused. We dilute vanc in 250 cc NS (we mix our own medications) and then hang it. We always make sure to check renal function and vanc trough prior to administering.

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6 Posts; 559 Profile Views

The vanco came diluted (pharm does it for us) and I piggybacked it onto 500ml NS, yes.

This patient also had IV NS with 40 of K+ ordered, so I had an entirely different set of primary tubing for that, and reconnected her after the vanco was finished. Maybe they didn't like that I had a second primary tubing hanging by the pump?

The Phenergan- at the time I was giving it, I thought it was to be given IV. By the time they came to talk to me about giving it, it had been quite a few days since I've had the patient and she was already discharged, so I don't know if/how they can go back to check.

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65 Posts; 3,628 Profile Views

The only thing I can think of is that maybe they think you should have started another line for the vanc so patient could continue to get her K+? Now I'm curious. Please keep us posted and good luck.

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AceOfHearts<3 specializes in Critical care.

888 Posts; 14,454 Profile Views

The vanco came diluted (pharm does it for us) and I piggybacked it onto 500ml NS, yes.

This patient also had IV NS with 40 of K+ ordered, so I had an entirely different set of primary tubing for that, and reconnected her after the vanco was finished. Maybe they didn't like that I had a second primary tubing hanging by the pump?

The Phenergan- at the time I was giving it, I thought it was to be given IV. By the time they came to talk to me about giving it, it had been quite a few days since I've had the patient and she was already discharged, so I don't know if/how they can go back to check.

I think vanco might be compatible with potassium chloride (I'm at home, so don't have access to lexicomp or micromedex like at work), so maybe that's why they want to talk with you- to see why you hung new tubing and didn't just piggyback it. If that's the case they might also want to make sure you are comfortable with the resources available to check compatibility of IV meds- which should be done any time meds are being run together on the same line or y-sited in together.

As as for looking at the chart for the discharged patient, there def. is a way to look at it. I don't know the process for your facility, but at mine anyone can look up charts of recently discharged patients up to 2 months post discharge (and I'm sure there's a way to look at them after). I know this because it's done the same way as patients discharged within the last 24 hours and sometimes I need to write a discharge note on a patient after they've been discharged from the system (if I don't have time to write the note just after they leave).

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35 Posts; 1,768 Profile Views

At my hospital we obtain trough levels prior to the 4th dose of Vancomycin. Could this have been overlooked? It really bothers me when I am told "We need to talk about..." without details. I become nervous also. Good luck

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HouTx has 35 years experience as a BSN, MSN, EdD and specializes in Critical Care, Education.

9,051 Posts; 45,043 Profile Views

My organization has nearly a total ban on peripheral IV phenergan because of the horrific consequences that are associated with it, including loss of limb. When in doubt & no policy is available, I suggest always calling the pharmacist for more information - that's what they're for.

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AceOfHearts<3 specializes in Critical care.

888 Posts; 14,454 Profile Views

When in doubt & no policy is available, I suggest always calling the pharmacist for more information - that's what they're for.

I wish there was a love button!

This is some of the best advice you will get. I've done exactly this and have avoided med errors as a result. Doctors and pharmacists are humans and capable of making mistakes just like nurses, so double checking never hurts. I've questioned an order before that the doctor messed up and the pharmacist didn't catch the mistake either- it was corrected before it caused a problem because I asked questions.

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101 Posts; 3,974 Profile Views

If you facility has a ban on Phenergan IV, why were you able to scan it and administer it? That is a change that needs to take place in another department so that IV Phenergan isn't available to anyone but pharmacy. As for the vanco, it sounds like you piggybacked the vanco onto another 500ml NS bag as the primary? If that's the case, you didn't really need to do that. The vanco came adequately and properly diluted from pharmacy so if it wasn't compatible as a piggyback on your other fluids, you could have just ran it separately as its own primary. I don't see a safety issue but you wasted a 500mL bag of saline. I don't see any other issues.

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1 Article; 1,509 Posts; 14,562 Profile Views

The only acceptable answer to "how to give medication" is to

1. Ensure the medication is ordered

2. Can the medication be given on your floor??? Certain medications are restricted to critical care or procedural units or even certain tele units. There should be a list somewhere or it will be outlined in policy and procedure.

3. Always look at policy and procedure for medications you have not given yet - it is usually online - make sure you know how to look up that stuff and that you understand. For example, it could tell you that you are allowed to give phenergan iv but only 12.5 mg iv . That makes the MD order invalid because they are not allowed to order against P & P (the whole point of P & P is safety).

4. does the patient have the right access? some meds can only be given via central line or certain concentration have to be central line.

5. the 5 R - I guess now there are more R but you get the idea

6. don't forget to check for allergies - pharmacy and the POE should catch errors - having said that - it does not always happen.

6. Every medication can have side effects. When somebody has a PIV it is important to flush and ensure it is still ok before hanging iv meds. Certain medication should not be given iv or only diluted in a certain way - again P & P - and pharmacy should mix most meds in the right concentration.

7. I the pat complains of burning, even it is at night, you need to stop the iv and switch on light, look at the side. It is often the first sign that the access is not ok anymore. In that case, instead of just ignoring it and tell patients that it is normal to burn, you want to get a new PIV. If it burns and you ignore it, and next day there is a phlebitis or swelling, and the patient says that he complained about burning - it looks like you ignored an important complain and sign that something is not ok.

8. You need to know the most common meds given on your unit and the usual problems with it. Keep a running list or small notebook and take notes.

Strategies to improve your performance are to follow the steps for medication administration as above - just scanning in and passing the scan is not a guarantee that you have done everything you have to. Scanning is only one tool to ensure more safety but there are other things. Make sure you check the identity when you make your first round. I always asked the patient for their name and DOB and compared it to the wrist band. Because if billy joe has the wristband for bob it could still happen that billy joe gets the wrong medication.

Only take out medication for one patient at a time. Do not take out more than that.

If you have problems remembering everything I suggest that you look in the P&P and print out the most important sheets and keep a folder at work for quick references though P & P get updated regularly. Some places have grids to help new nurses - perhaps there is something like that - you can ask the educator. Buy a small notebook that fits into your scrub pocket and write down important things like "metoprolol iv can only be given when on tele" or vanco iv always needs a pump - too fast can cause red man syndrome.

If in doubt ask another nurse to check with you. There is no shame in asking another nurse to look at an access if you are not sure it is ok. I have done that many times when it looked ok but the patient complained to have second pair of eyes. Or I have called the iv nurse when the place had an iv team. Better safe than sorry.

They want to talk to you about your thought process to ensure that your overall working is safe and you understand the risk and problems with medication administration. You need to show that you have critical thinking and that you know when to stop something and get more information or advice. For example if you want to give an im medication - do you know the right needle length? can you even give it im? which muscle is preferred? which technique? I think you get my points.

Specifically for vanco there is even more :

Does the patient need a vanco level??? if yes you need to draw the level and wait for results before you give it. If he level is above a certain number, usually 20, you have to call the MD and ask if it should be given or held if there is no order already. I have seen patient in acute kidney failure because the vanco level was not ordered or drawn and vanco level was very high.

It needs to be diluted the right way but also has to run a specific amount of time, usually an hour but if it is a high dose, it could be longer - the label on the bag should tell you. If you have a smart pump - do not work around it - always use the smart pump functions.

Once you have put the meds in the pump stop a second to think about your calculation - does the rate make sense? If you have a 500 ml bag and it should run over an hour that is a lot of fluid that gets pushed through a small PIV and if you have an elderly patient with heart failure - could that cause other problems like CHF?

The thing in nursing is that we all make mistakes because we are human beings. That is why we put systems in place to help us to minimize errors. But we need to follow them / be compliant otherwise we work around and the risk of making a mistake is higher. It does take time to give medications and safety comes first. Night time is a time where errors can happen easily.

I have made mistake in my many years of nursing. We all do. We are accountable though and need to strive to cont improve.

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