IV drip dose error

Specialties MICU

Published

I work in an ICU setting in the nights. My patient who is intubated was on a Fentanyl drip at the rate of 150 mcg, for the whole shift. Just at the end of the shift since I had to turn my patient i increased the dose to 200mcg. After I finished turning him etc.. I meant to go back to the original dose that was 150 mcg, but I was in a hurry and I accidentally put in 15mcg instead of 150. I did not realize this until i reached home and received a call from the nurse to verify the dose. The patient basically received a 15 of fentanyl for about 1 hour or so.I am new in the ICU ( less than a year) and this is the first time this has happened. I am not sure what they will do about this but the Rn seemed pretty upset about the situation. How big of an error is this? Also, we always check the drips after giving report, but the RN got busy with the other patient and said she will do later. I have learnt my lesson to be careful and not rush with medications. Any input/ advice will be highly appreciated.

Specializes in Cath Lab/ ICU.
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Sure the patient could have extubated themselves being too alert on 15 mcg, but if they're that confused they should probably have been restrained too.

HA!! that's funny!

Back in the day we could rely on restraints as a safety barrier to prevent self extubation. But today??? Today, we cant just restrain anybody because they are confused and intubated.

No, we can hardly restrain at all!! I have to jump through mor hoops than it's worth. Chart every intervention that I've tried before restraints, notify my manger, CNO, etc...

Basically, we can't just restrain with abandon anymore. Even when it's really, really, REALLY necessary!

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Specializes in ICU-my whole life!!.

Stop sweating it. You gave your pt an unscheduled med vacation for an hour. Your coworker on the other hands sounds like a moron because now they feel they have to bust their tail.

I guarantee you that you will never make this "mistake" again. They are some of your best teachers.

Make it a practice to check all your gtt's before change of shift from now on.

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Specializes in ICU & ED.

God, I know how you shaky you must feel... I hung the wrong MIV fluid (.5 NS vs NS) on a patient when I was rushed... Small potatoes, no harm, no foul... BUT it still bothers me after many years. So I agree... Be thankful there was no cumulative harm to your patient and be careful!

Also, pass along the lesson you learned when you get to precept or mentor others! I know this will make you a better nurse!

Of course sharing your story here will helps others, too!

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Seems maintenance fluids are a big problem as nurses overlook them. I had a guy come over with a KVO of D5W with an insulin drip from the SICU. Turned off both, blood sugars were fine lol.

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Specializes in Professional Development Specialist.

Take it as a very valuable learning experience. Don't rush, and always triple check. You got great advice from experienced ICU nurses here.

Then remember that some nurses like to take those mistakes and use them to make you feel small and stupid so they can feel good. Take her reaction with a grain of salt. Some of the worst nurses I've known have spent so much time trying to catch others that they were commiting serious errors on their own every single shift. Every write up was a litany of complaints about things OTHERS had done and therefore their mistakes shouldn't count. But in the real world nursing doesn't work that way.

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Specializes in Cath Lab/ ICU.
Seems maintenance fluids are a big problem as nurses overlook them. I had a guy come over with a KVO of D5W with an insulin drip from the SICU. Turned off both, blood sugars were fine lol.

But how was his gap?

I see nurses all the time turn off the insulin gtt prematurely because they didn't understand the pathophysiology of dka.

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Specializes in ER/ICU/STICU.
But how was his gap?

I see nurses all the time turn off the insulin gtt prematurely because they didn't understand the pathophysiology of dka.

How do you know it was dka? Some facilities, especially in surgery, like too keep tight control of sugars and people may be put on insulin gtts for that. The patient could also have been hhnk. I agree with you though about the gtts being shutoff early. Our insulin gtt protocol specifically states that it is not to be used for dka.

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Specializes in Cath Lab/ ICU.
How do you know it was dka? Some facilities, especially in surgery, like too keep tight control of sugars and people may be put on insulin gtts for that. The patient could also have been hhnk. I agree with you though about the gtts being shutoff early. Our insulin gtt protocol specifically states that it is not to be used for dka.

I *don't* know it was dka-that's why I asked about the pts gap. And that's why I explained that I see people turning off insulin gtts all the time in pts with dka...I also understand the difference between dka and hhnk (tyvm).

My point was, sugars arent always an indicator of the need to turn off insulin gtts. I've actually had an insulin gtt running at 0.2 units/hr and it was very necessary, and part of our insulin protocol for dka.

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Specializes in ICU, Postpartum, Onc, PACU.
I agree, ALL medication error is a big deal! Just be careful next time and learn from your mistakes. :)

Definately agree! Once I thought I'd given too much of a medication for some reason (there wasn't even more than the intended dose in the vial!! haha), and I was sweating bullets until I realized there was no way that could have happened.

Please PLEASE freak out over this small one and let it be your only one, since no harm came to the patient. It's really scarey when people act like it's no big deal (probably just trying to make you feel better, which is kind) because it COULD have been something much worse. This is a good little wake-up call for you. We've all made an error, small or large, or will and it should freak you out. It's truely scarey when people act like a med error or near miss is no big deal.

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Specializes in NICU, Post-partum.
I work in an ICU setting in the nights. My patient who is intubated was on a Fentanyl drip at the rate of 150 mcg, for the whole shift. Just at the end of the shift since I had to turn my patient i increased the dose to 200mcg. After I finished turning him etc.. I meant to go back to the original dose that was 150 mcg, but I was in a hurry and I accidentally put in 15mcg instead of 150. I did not realize this until i reached home and received a call from the nurse to verify the dose. The patient basically received a 15 of fentanyl for about 1 hour or so.I am new in the ICU ( less than a year) and this is the first time this has happened. I am not sure what they will do about this but the Rn seemed pretty upset about the situation. How big of an error is this? Also, we always check the drips after giving report, but the RN got busy with the other patient and said she will do later. I have learnt my lesson to be careful and not rush with medications. Any input/ advice will be highly appreciated.

This is minor, not major, in the grand scale of things.

However, in my facility, both nurses are at the bedside and verify the IV rates together.

If you have multiple fluids running, FOLLOW each line FROM each bag to each drip port to make sure that what you THINK is running is actually running. Sometimes bags and tubing gets changed and puts back in the wrong port so you discover later it is at the wrong rate....yup, happened to me...that is how I know to check it now.

I always, after resetting a pump, take one last conscious look before walking away and say to myself, "Ok, 150 mcg per hour..."

I got in a hurry once and screwed up huge...never, ever again.

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Specializes in ICU.
Definately agree! Once I thought I'd given too much of a medication for some reason (there wasn't even more than the intended dose in the vial!! haha), and I was sweating bullets until I realized there was no way that could have happened.

Please PLEASE freak out over this small one and let it be your only one, since no harm came to the patient. It's really scarey when people act like it's no big deal (probably just trying to make you feel better, which is kind) because it COULD have been something much worse. This is a good little wake-up call for you. We've all made an error, small or large, or will and it should freak you out. It's truely scarey when people act like a med error or near miss is no big deal.

Please don't 'freak out' over anything in the ICU. That's not the place.

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Specializes in ICU, Postpartum, Onc, PACU.
Please don't 'freak out' over anything in the ICU. That's not the place.

I didn't mean AT WORK....obviously that's not the time or the place (I should've been clearer). I meant that it's not something to be taken lightly even though it was a minor mistake. I just meant that maybe it should make you sweat a little, make your heart race a little, and make you hyper aware of everything you do after that.

Even after I almost hung the right drug, right time, right dose, right route one night, it had my other patients' name on it and that freaked me out that I'd gotten busy and let that go, even though everything would've been fine.

Like the other people said, it's a learning experience, tell yourself your still a good nurse, and that you've learned your lesson and move on from there. I just felt like everyone was making light of a med error and I think it should make you quake a little when something like that happens.

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