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Antikigirl Antikigirl (New Member) New Member

Live and learn...my med error!

Nurses   (6,257 Views 39 Comments)
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You are reading page 3 of Live and learn...my med error!. If you want to start from the beginning Go to First Page.

I think you're a terrific nurse for sharing your story. Errors happen; thank God no one was hurt. The most difficult part for the nurse is forgiving him/herself and moving on with confidence. I hope you can do that.

elisheva excellent post couldn't have said it better myself .

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triage nurse thankyou for sharing .that was and excellent post and i too believe we learn form eachother.i love this forum.i am glad admin supported you .that was a load x2 none should have had to do ie one float get 1 assignement and 4 hrs later get reassigned new floor new pts.

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For the people here who are not yet in the know...

PCA is where the patient is able to give themselves medication as needed?

 

I read both drugs are give to patients who have undergone surgery or severe injury. what are the major differences between the two? Is one stronger than the other?

 

So the patient gave themselves a few mg of Dilaudid. What are the consequences of this?

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Ttriage, I read your post and commend you on sharing. What a horrible situation to have to deal with. I believe scenerios such as this a are contributing factor as to why we have a nursing shortage. Thank goodness you recieved positive support at your place of work.:wink2:

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Thank you for sharing your experience. I am new RN, only been out of school for 1 year, and it is nice to learn that we're all doing our best for patients' safety and our own sanity. I try my best to triple check every medication because in the back of my mind I know that we are only human and can all make accidental mistakes. I'm glad you are OK and that you have a good support system at work.

again, Thanks for sharing!

;)

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You know what, I respect you so much. You sound like you have integrity and want to learn and help others learn, from this. BRAVO. All it takes is a second and we could hurt or kill someone with just "one tiny error". Can't be stressed enough to check, double check, triple check. My hat is off to you. You care.

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For the people here who are not yet in the know...

PCA is where the patient is able to give themselves medication as needed?

 

I read both drugs are give to patients who have undergone surgery or severe injury. what are the major differences between the two? Is one stronger than the other?

 

So the patient gave themselves a few mg of Dilaudid. What are the consequences of this?

PCA = patient-controlled analgesia. The patient's IV is hooked into a pump that contains a medication syringe. Using a button on a cord that comes off the pump, the patient can receive a dose of pain-relieving medication. The amounts of medication released with each push of the button are tiny, and there is a lockout time so the patient cannot overdose.

The problem in the OP's situation is that different medications have different concentrations and different dosages. Dilaudid (hydromorphone) should be given in much smaller increments than morphine. In this situation, I believe, the morphine syringe (requiring a larger dose) was accidentally replaced with a Dilaudid (hydromorphone) syringe (which uses a smaller dose).

The end result was that while Dilaudid may in some ways be a safer med, it is NOT safer when given at the higher dosage that is intended for morphine. If the error had not been caught quickly, the patient could have received a dangerous or even lethal amount of medication. Had the doc truly changed the dosage, the pump should have been reprogrammed to give the smaller dosage.

This is a well-known hazard connected with the use of PCA pumps, common enough that the ISMP (Institute for Safe Medical Practices) includes this among their recommendations for drug manufacturers and pharmacists:

Distinguish the packaging of opiates and the varying strengths used for PCA. Use "tall man" letters for HYDROmorphone to help avoid confusion with morphine.

Thank you, Triage, for bringing your scary experience to your hospital's attention and for sharing it with us. Your openness and honesty may help to save someone else--staff member and patient alike--from serious harm.

I know I will certainly keep this in mind as nearly all the c-section patients that come to my postpartum unit arrive with PCAs. I changed the syringe in one last night and you'd better bet that, as a result of this thread, I triple checked the label and will continue to do so. It isn't enough for me to rely on the fact that we generally use only one kind of med syringe. The NICU nurses in Indiana who gave adult doses to six babies (three of whom died) did so because a pharmacy tech stocked the wrong syringes in their med supply.

Thanks, again, Triage, for offering many people the chance to learn a valuable lesson.

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thanks for sharing... wow.

Had the same thing happen in clinicals (someone else- an employee) gave so much Dilaudid (doctor's mess ended up that pharmacy didn't do it right and nurse didn't check). Woops! Pt went downhill, hardly breathing and his bp was looooooow, they did catch it on a routine check on his room, thank god, but the nurse who gave it got a new orifice and we were all told to stay out of her way.

So have the geniuses who run this hospital ever heard of Computer Physician Entry Order (CPEO) systems? Just from what you have told me here (assuming this is the whole picture), this is probably not the first time something like this happened nor will it be the last. Nor was it the nurse's fault.

I am not a medical professional but a quality management professional-- and the solution is obvious to anyone in my field.

(1) The doctor enters his prescription into a computer (e.g. a portable data assistant that is connected to a central computer) as opposed to scribbling it in "doctorese."

(2) The computer checks for dosage errors (e.g. typing an extra zero or misplaced decimal point) and interactions with anything else the patient may be taking.

(3) The computer sends the prescription to the pharmacist. Since the dosage is typewritten-- and perhaps written out the way we write dollar amounts on checks-- there is far less chance of a mistake.

(4) The medication goes into a bar-coded package, which the nurse checks (using a bar code reader) against a bar code on the patient's wristband. This makes it impossible to give the medication to the wrong patient.

And this is just off the top of my head. I'm not sure why these hospital administrators get six-figure salaries to discipline the nurses instead of fixing their systems (where the real problem is) when these things happen but I resent it. I'd be glad to take their jobs for half the pay and I WOULD fix the problem instead of blaming the nursing staff.

As for the nurse not checking-- well, perhaps she should have done so, but it is a general rule in industry that any job that requires "operator vigilence" is poorly-designed and a mistake just waiting to happen. No matter how diligent the nurse is, it is only a matter of time before a poorly-designed system will end up killing someone.

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...The problem in the OP's situation is that different medications have different concentrations and different dosages. Dilaudid (hydromorphone) should be given in much smaller increments than morphine. In this situation, I believe, the morphine syringe (requiring a larger dose) was accidentally replaced with a Dilaudid (hydromorphone) syringe (which uses a smaller dose).

...I know I will certainly keep this in mind as nearly all the c-section patients that come to my postpartum unit arrive with PCAs. I changed the syringe in one last night and you'd better bet that, as a result of this thread, I triple checked the label and will continue to do so. It isn't enough for me to rely on the fact that we generally use only one kind of med syringe. The NICU nurses in Indiana who gave adult doses to six babies (three of whom died) did so because a pharmacy tech stocked the wrong syringes in their med supply.

I've never seen a PCA pump but a relatively-obvious solution comes to mind. I assume there is some kind of fixture through which the syringe is attached to the pump. The syringe's front could conceivably be equipped with a key or slot-- one kind for Dilaudid and the other for morphine. A morphine syringe should not fit a Dilaudid container and vice versa. In other words, if the pharmacist tries to fill a morphine syringe (meant for the PCA pump) with Dilaudid, he will immediately see that it won't go into the medication bottle. Furthermore, the syringe key or slot will tell the PCA pump what kind of medication is being used.

The idea comes from industry. A gas valve for an oxygen line won't fit a hydrogen tank, and vice versa. The idea is to make it impossible to blow yourself (and the factory) up by connecting oxygen to a hydrogen system, or vice versa. Henry Ford's principle was, "Can't, not don't." Instead of posting signs that tell workers, "Don't put your hands in the machine," you design the machine so the worker CAN'T put his hand in the machine. As an example, mechanical presses require the operator to press two switches, so the machine "knows" where its operator's hands are before it comes down with several thousand pounds of force.

Anyway, the PCA should (ideally) be designed so you can't put the wrong medication in, or so the device will "know" for certain what kind of medication is present.

Another thought is as follows. I don't know how far infrared chemical analyzers have progressed since I was a chemistry student, but it might be possible to install them in PCA pumps (or other IV devices) so the device itself can check the identity of the medication that is being used.

The incidents you are describing simply reinforce my opinion that 80-85% of all "malpractice" (and "nursing errors") come from the system in which the medical personnel must work as opposed to behaviors for which anyone should be sued or disciplined. The hospital administrators are responsible for the systems and, if the systems end up harming patients, that is where the blame should fall.

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Hospital equipment comes with messages that its limitations should not be exceeded. Maybe hospital personnel should be labeled with a similar caution.

Your double assignment was a mistake (or ten) waiting to happen. Too much to keep track of, too much to do, too much to anticipate. You already had a heavy load. Then you were blind-sided with a whole new assignment when you were pretty well used up. Adrenalin carries you only so far.

I reiterate--if you were a piece of machinery, they'd know not to overload you or you might blow a fuse.

I'm soooo glad the patient and her unborn child are okay. And I'm happy the rest of the staff is standing by you and that the hospital is using this as a learning opportunity for everyone. They truly owe you an apology for putting you in such an untenable position, but at least they aren't turning you into a scapegoat.

Thanks for having the courage and the consideration to share this with the rest of us.

Learn what you can from this and then LET IT GO.

Beautiful post. I agree wholeheartedly with all you've written here.

Triage, you are soooooooooooooooooooooo fortunate to have such a supportive group all around you! Very rare these days. You can count your blessings in more ways than one!

Thanx for sharing, and relieved to know mom and baby were not harmed. I know your pride and spirit was, but it WILL heal ! (((HUGS)))

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Thank you guys so much for all the kind words of support!

Yesterday I went back to work and sure enough...they floated me again! LOL! But I stood up for myself and told the administrative nurse there that once I hit a floor, please keep me on that floor! The administrative nurse that was working that night said he heard about what happened and was totally upset and what happened to me (he is a very seasoned administrator), and that he doesnt' do that to anyone (proably the reason I have never had this happen before...a newer administrative RN was on duty). And he kept me on my assigned floor! YEAH!

Not to mention I had NO PCA's..LOL!!!!!!!!!! I said "what..no PCA's...ohhh now come on! LOL!". We got a good giggle, and they know I will be watching out carefully, and am not so upset I can't work or put a fun spin on the occurance in order to stay a chipper nurse! I had awesome pts last night, had time to help out other nurses, and enjoyed my work day as I normally do! And it seems when I am being fun and chipper, everyone else is...heck a MD who is usually so tired they can't see straight was laughing and having a blast on our floor!

I won't let it get me down, but will use it as a learning experience and continue to share it with others so they don't make that mistake, and share ideas to my admin about how to overcome errors on this and other things I find along the way. Heck, by sharing the experience at work, us nurses have already come up with about 5 great working ideas on how to avoid this type of error, and it won't cost anything more! :)

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Wow what a hard lesson t have to learn. Kudos to you for being up front, and boo to the scheduler who put you in that terrible assignment. However praises are due your administration for realizing this awful system error.

For the members who don't know about PCA's there are so many different brands and styles within brands. The only one I am totally familiar with is the Abbott PCA

tkpcapump-AA.jpgPump. It has a plastic door that has to have a special key in order to open it.

The syringe sits "upside down" and a clamp grasps the plunger wings and pushes the medication into the tubling in small increments. Morphine and Demerol were the only drugs bought retail and our pharmacy filled syringes for Dilaudid. The pump settings are different for each drug. One ml could contain 1 mg Morphine or 10mg of demerol or 0.1mg of Dilaudid. There is massive potential for mistakes.

Eight total care post op patients is unreal. I admire Triage so much for doing what she did, but I believe next time (and there will be a next time) any nurse should just say NO.

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