Today I gave my pt. 2mg IV Ativan for anticipatory anxiety for a MRI. Her order was for 1mg, I obviously read the order wrong.
Later in the day, she was difficult to arouse, but her VSS. The following RN elected not to give any form of pharmacology reversal (Narcan), and called the SUP.
The pt. was sent to the ICU and now is vented.
I'm so sick thinking of what I may have done to this woman. Can anyone please tell me of my rights as a RN? I spoke to my SUP and admitted "I read the order wrong". Any advice would be greatly appreciated. I've a stellar Nursing record, and I can't even think of the worse case scenario.
Because I expect that when we, as professionals, medicate a patient we take the time to monitor our own actions and take accountability for our mistakes.
The OP made a med error. Did 2mg of ativan send a patient to the icu? Probably not. The issue is the OP made a medication error and instead of looking for ways to prevent this in the future we are placing blame on everything but the one person who could've prevented the error, the nurse.
Being short staffed and not having someone to waste 1mg of ativan with does not mean we waste it in the patient. This patient was not crashing and this was not life saving ativan. The nurse was not paying attention and gave a full dose. They are not the first to overmedicate a patient.
Instead of focusing on how the OP could prevent this error in the future they made the choice to bad mouth another "drama" nurse who allegedly gave a full bottle of insulin IV push. This is all a method to make the med error seem less important to the OP. "I did this, but at least I didn't do this" mentality.
I am not the problem with our profession. The problem is those individuals who minimize their own actions and don't realize that the next mistake could cost a patient their life.
I'm not saying nurses should be fired or scolded for making medication errors. I'm saying that when we make an error, we need to own it and make sure it doesn't happen again. Throwing another nurse under the bus to save ourself or make us look better is not acceptable behavior.
As others have said, there was probably something else going on with the patient. However, for a 75 y/o pt, 2mg of Ativan IV prior to an MRI is definitely a hefty dose and I would question that in the future. We usually give pts po or sq doses (gentler, lasts longer, etc.) prior to this procedure. Did the patient have any comorbidities (i.e. kidney or hepatic problems) that would affect the pharmocokinetics of the medication? An elderly patient with these issues could fail to effectively metabolize/excrete this medication and that could certainly prolong their drowsy state and their capacity to protect their airway.
Hopefully you are not punished for this mistake as everyone makes medication errors at some point in their careers. A punitive culture deters people from reporting med errors and prevents systemic improvements that can prevent the same mistakes from reoccurring. It sounds like you've learned something from this incident and you will be a better nurse in the future because of it. Make sure that you carefully reflect on what happened prior to the error (were you in a rush? was the doctor's writing hard to read? etc.) and try to think of ways to make it safer for you, your colleagues, and (most importantly!) your patients in regards to similar incidents in the future.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
Its good and proper that you recognize your accountability in making an error. I would consider this to be a very MINOR med error. That said your job should not be at risk for something like this. At most there should be a review of systems to allowed this to happen and some re-education for you. Hospitals that punish good nurses for making a minor error only encourage others to not admit when they have made an error.
If they fire you I guarantee other nurses may think twice before admitting it when they have made an error. If they don't fire you I suggest looking for another job. Who wants to work for such a crappy place where something like this could cost you your job?
Specializes in Oncology, Rehab, Public Health, Med Surg.
I completely agree with you. Yes, it's my nursing judgement to give the med before the procedure, and yes, it did probably pop up on the scanner. I probably dismissed it, I don't remember. The thing is, at times we are so short staffed there is no other RN to waste with. Welcome to my biggest fear!
Now,that's what scares me also that she did not advocate for flumazenil, coming from a RN who gave a complete bottle of insulin thinking it was protonix. I digress.
Thank you so much for the tip on calling malpractice insurance carrier for advice. I'm really naive when it comes to admin things.
I was totally with you until this post--- ( ok I'm still with you but not liking this post much)
Right or wrong, this is what i would interepret the above as - ( in parentheses)
Probably did pop up ( computer warning)--(too busy for saftey warnings)
Probably dismissed it ( computer warning) (ditto)
I dont remember....( too distracted to remember giving narcotic)
So short staffed.....( external reason caused me to make med error)
Welcome to my biggest fear ( situation so scary I'm not in control of not making error)
No one to waste with......
Scary other nurse didn't ......(im not the worst one so that makes this mistake better)
Scary other nurse also gave....
I'm also one of those that don't see this as a huge error- this didn't put her on a vent- esp 5-6 hrs later. If I heard the reasoning above though, I'd have red flags going off as a superviser.
See, there's no way as a sup that I can tell you that you won't be short staffed again, work with drama producing nurses again, always have someone right there to waste med with etc. So i need to know how you will make it different next time these circumstances happen---and they will
What I would want to hear is you taking accountability for your error, what you learned from it, and how you will make sure you don't make that kind of error again. That it's you in charge of your environment, not the scary, busy , drama-nurse filled enviroment in charge of you
I really am on your side. i have certainly made what I would consider more serious errors in my 30+ nursing career.
Just give it some thought-- how do you want to present yourself in this situation?
Today I gave my pt. 2mg IV Ativan for anticipatory anxiety for a MRI. Her order was for 1mg, I obviously read the order wrong.
Later in the day, she was difficult to arouse, but her VSS. The following RN elected not to give any form of pharmacology reversal (Narcan), and called the SUP.
The pt. was sent to the ICU and now is vented.
I'm so sick thinking of what I may have done to this woman. Can anyone please tell me of my rights as a RN? I spoke to my SUP and admitted "I read the order wrong". Any advice would be greatly appreciated. I've a stellar Nursing record, and I can't even think of the worse case scenario.
Thank you.
The 1 extra mg of ativan is not what sent this patient to the ICU. Narcan is the reversal agent for opioids, not for benzodiazepines. Romazicon can be used for benzo reversals. There has to be more to the story. Was the patient breathing/ventilating properly? Did they check an ABG? Altered mental status is not a good enough reason to intubate someone unless there is something else going on.
Specializes in Case mgmt., rehab, (CRRN), LTC & psych.
I've come to believe that any nurse with a significant experiential level who insists (s)he has never made a medication error is telling a boldfaced lie.
Medication errors happen to even the best of us. The important thing is to live and learn from them. Good luck to you.
#27 is a great post and exactly what I would have said, only not as well, I think it was also what the other reality-check nurse was getting at.
OP, others have explained everything to you about med errors and Just Culture. We've all been there. But part of Just Culture, part of teamwork, is not gossiping. You shouldn't even know about your co-worker's mistake with the insulin, unless she told you herself. We DEFINITELY shouldn't know about it, even if presumably none of us know her; what was your reason in saying so? You can only control your own behavior, not hers or anyone else's. And next time it may be you, or me, or the supervisor who gives the bottle of insulin. Be kinder to others than they may have been to you.
I would suggest asking your nurse manager if there is a safety event reporting system or something similar in your hospital. This is a computer program or form where you can document any event that related to patient or employee safety (I.e. A fall, a medication error, etc). I would suggest documenting that you acknowledged making the error and what steps you took afterwards to monitor the patient. Did you notify a doctor? What factors contributed? Are your vials of Ativan always 2mg and your unit typically only gives 0.5-1mg? That's a lot of wasted narcotic.
I made a similar error when I worked in hospital nursing. I notified the patients resident and documented a plan of how I would monitor the pt. I notified the patient and apologized. I filled out the safety event form. I also sent an email to my nurse manager (it was an off shift) detailing what happened and what I would do to prevent an error from occurring again.
Don't beat yourself up and take this as a learning experience!
Benzodiazepines are a sedating, potentially addictive, mind altering class of medications. Thus, they are a controlled substance, and considered a narcotic in many senses, being kept it "narc boxes" and such in the olden days.
Benzodiazepines are NOT opiates, which is what I suspect you are asking. Thus, Narcan, the reversal agent for opiates, is ineffective on them. Flumazenil is used to reverse benzos.
Highly doubt a correlation. Ativan 2mg is nothing. Although if the Supe thought it could be the cause, Flumazenil could have easily rule this in or out. Don't beat yourself up. you had NO ill intentions. I've seen it all...... This is not up there in the list of errors.
Learn about reversal agents and make a cheatsheet for yourself. We ALL make a medication or nursing error or two in our career. It's to be human.
I'll start by saying that it can happen to anyone. A lot of mistakes in healthcare (regardless of discipline) are "There but for the grace of God go I" moments. There is also research to suggest that many errors are the result of human error, yes, but can be broken down into systems issues. Don't beat yourself up too badly. Yes, it's a learning experience, but others have been there too. Also, there is no "not major" medication error whether the med is something "benign" (ex. docusate) or something "serious" (ex. proprofol/paralytic/IV benzo/IV narcotic).
1. Flumazenil is the agent you'd want for benzo overdose, not narcan (narcotics/opiates).
2. I'm assuming in your facility Ativan is dispensed via 2mg vials?
3. Does your facility have computerized medication administration? When I worked the floor we did, and when we scanned meds if the med scanned was 2mg Ativan and the order was 1mg Ativan it prompted us to waste 1mg. Our pyxis stations required us to note when "more" than ordered was dispensed and it was something we'd have to "come back to" to waste/verify (double internal documentation - the MAR and the pyxis could run reports for pharmacy). In one facility we had to cosign some meds for the MAR administration (not the ones you'd think necessarily, but still). Some meds we have to cosign, now, in the OR (mostly chemo).
4. Random question - while we're thinking learning and on this topic? How does your facility handle orders for narcan and flumazenil? Are they auto ordered / per protocoled when IV benzos or narcotics are ordered? Or do you have to contact the provider for those orders? I know it's common to give ativan or other drugs (IV benzos, narcotics) before sending patients for testing. You mentioned the patient was off unit for an MRI (so probably a 60 minute trip). The IV ativan would have peaked during this time. The other question is - if there are orders for flumazenil and narcan if the IV benzos and narcs are ordered, if needed, are these drugs something that test locations (radiology, etc) have in their pyxis or would you as a nurse have to pull the drug on your unit and take it to radiology?
I know from my experience - I sent plenty of patients to CT or MRI with an NA/transporter without me ever accompanying the patient. There were other patients I accompanied to MRI or CT but did not necessarily have to stay in the control room for. My sickest patients (usually stat CT scans for status changes) were usually a 2 nurse transport from our unit to ED CT and we never handed care over to the radiology staff, we were in charge of monitoring the patient unless the patient coded and we needed the code team. So I guess my question would be what is the plan if your patient needs these drugs and is off unit?
5. Regarding the situation you described. IV ativan. IV medications have an onset of how long after administration? A peak efficacy of how many minutes after administration? So if the patient was off unit for the test and came back, you reassessed them and found they were "difficult to arouse with VSS". You mentioned that the nurse to follow you contacted the sup (? house sup) and transferred the patient to a higher level of care where they were subsequently intubated/ventilated. If you consider when the IV ativan would be most potent to the patient and there is (as I assumed by your description) a time lapse? It's unlikely that the ativan was the cause of the issue. Question being what kind of MRI, what else could have gone wrong with the patient to warrant a higher level of care?
6. I'd still notify your malpractice carrier if you have one. Never know and transparency is everything.
7. I sincerely hope you completed all applicable documentation after the error was caught. I'd imagine you did. While not part of the medical record I hope you completed the incident report as appropriate. Never know, this might cause a change in policy/practice that helps prevent this from happening again.
8. I hope you notified the attending provider when you caught your error (I'd imagine you did but it wasn't expressly stated). They need to know, and need to be able to write orders or re-assess their patient based on developments in the patient's care. (And I hope you documented who you notified/what their instructions were).
I can't speak for certain what your facility will/will not do, as I do not work there. Many times though, based on what I've seen in the facilities I've worked in, things are treated as a learning experience. There will probably be some consequence but that is expected.
VANurse2010
1,526 Posts
i don't think anyone is saying it is.