IV drip dose error

[babbu]

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.

[suanna]

The nurse that called you at home took responsibility for the patient- that generaly means she checked off the IVs on hand-off. If it was running at the wrong rate for long enough for yo to get home before she called you on it, it is as much her error as yours. It all depends on how anal-retentive you are as to how you view this incident. From your explanation of how this happened it is pretty clear that you were acting in the intrest of the patient and just mis-entered the rate on the pump. I kinda think that is why we have better staffing in critical care and nurses at the bedside. With the number of titrations that happen on a critical patient in a shift the odds of an erroneous entry go up pretty high- you can't get rid of all human error. The important thing is the error is noticed and corrected before harm is done to the patient. Where I work our pumps can be titrated in mcg/kg/min. It is very easy to punch in 15mcg/kg/min on your neo drip instead of .15mcg/kg/min. See a change in your patient you don't understand? Did you touch the pumps recently? That is the first thing I check. Sure, you made an error in settings. That will happen from time to time. The important thing is when it was caught and what was the effect on the patient. In this case- no harm/ no foul. In the future, I would give a bolus or push dose to provide sedation pre-proceedure, and leave the drip rate alone. Don't let this make you nuts. The nurse that called you at home was being a witch and was trying to get your goat. Put your goat away and let it drop. If she brings it up again I would certainly ask her why she didn't check her pumps for so long after she took report. Dosen't she know how to assess a patient??!!

[I_See_You_RN]

I do agree that every medication error is a "big deal" in theory because the issue is the the action (or lack there of) and not the consequence. You were lucky since it was just a fentanyl drip and 15mcg/hr is not a problem.. call it a sedation vacation or an agressive titration off , but what if we were talking about levophed/dopamine/cardene.... then it could of been a HUGE problem.

she should not of called you and scared the bejesus out of you... I would of waited till you came back,.. told you about it nicely and firmly reminded that its very important to do double checks ,.. and the one thing that can't be rushed is medication. If she wasn't so high and mighty she should of also apologized because it is her duty to double check with you.

Don't let this bring you down, just use this as a learning experience. :)

[funkywoman]

Learn a lesson, take it seriously because it was an error. Realize that NO HARM came to the patient and don't beat yourself up about it. Learn and move on.

[wanderlust99]

I screwed up one time on a drip and could have KILLED my patient with a pressor and putting in the wrong rate(that was VERY high is all I'll say). It was horrible. I think I shook and was in a state of shock for several days. I was hysterical crying home. It was the end of the shift, I was busy all day and just worn out. Nonstop. I think that's why I made the error, I wasn't thinking clearly and was rushed.

I think it just shows what a great nurse you are that you're so concerned about this, b/c yes maybe you're patient would have been agitated & possibly self extubate, but really a smaller dose of Fentanly for an hour or two is not the end of the world.

A lot of hospitals utilize tools where you can report this. Maybe if you do, your management will really enforce the change of shift drip checks and that nurse would have known it's not a possibility to skip the change of shift drip check. I know where I currently work, the change of shift drip check is not done at all (I'm on a travel assignment).