i had to complete peritoneal dialysis for a patient twice a shift. order stated 2000cc from a 2500cc bag.
normally, a prompt would show up if it was for a pill. for example:
--"READ THIS: only administer 12.5 mg of 25 mg"--
the offgoing nurse told me what the pt likes to watch, eat, favorite hobbies, etc... BUT failed to mention "only give 2000 of the 2500 bag". keep in mind, we do have a 2000cc bag and they BOTH can be scanned interchangeably. i have no idea why/how? so i figured, IF IT SCANS... nothing more to it. i didn't notice the order, as i never experienced this.
my fault... for not reading the order. but how do i go about resolving this? as so it would NEVER happen again. i had to file a "risk" report...
i called the MD and no orders were given. they told me the order was because the pt was retaining fluids. i input 2500 and received 2300, twice. other times, i had patients retain more than this and no such order was given... so i didn't even bother second guessing. i am going back again... hope i didn't injure the person.
Is this related to the patient you had who had a mistake and died in December or is this a different patient? Is this patient still ok or did he die too? I think all you can do if this is a new situation and a different patient is to learn from it by not making any more mistakes like this! be sure to read orders carefully and be sure when you take out meds you check them carefully against the orders or the medrec sheet, whatever you're using. Everyone makes mistakes but if you're a new nurse and this is the second patient that has died under your care you are not likely to be in nursing for long. Unless maybe this patient turned out fine?
Always check the orders. Never go exactly by what u heard in report because that info could be wrong
yeah... i started to slow down. DON wonders why i am spiking in OT. i told her they can't dump on me the type of patients they do and expect me to finish on time. patient safety and my license is my priority. sorry boss...
apparently, this error happens more than none. it will again... and i hope nobody dies this time. hospital won't order the correct bags and pharmacy will not create a prompt for it. i had a 30 year old RN made a different mistake the other day, but she didn't get written up because she retired that weekend. mistakes happen people... only trying to see if anybody has any ideas... besides what my username was ... and clearly (i should've read that order, properly) :) thanks all.
i didn't make this post trying to shift blame. i made the mistake and own up to it. seems like somebody/somewhere on AN is trying to find an angle to **** on anybody.
Magsulfate, BSN, RN
1,201 Posts
Did I miss something?