Med Error Advice...

[brockclan3]

I work as an LPN at my hospital emergency department. I am a new nurse (5 months) and stared out in the ED. On my last shift we had a patient that had just returned from radiology. I was helping the xray tech getting him hooked back up on vitals monitoring and I reattached his IV line and unclamped the line. I went back to my desk and was working for roughly 5-10 minutes when patient's RN came and asked me if I had started the Vancomycin in room 3. I said that I hadn't, thought for a moment and realized I had hooked this patient back up to his bag of fluids. She told me that it was Vanc and I had just bolused the patient. My heart sank! I did not ask the RN or even think to check the bag. She told me that you don't bolus Vanc, which I know that it has to be infused roughly over 1-2 hours. I immediately called my supervisor to let her know what happened. I also filled out an incident report. I monitored the patient for any adverse side effects for the duration. Thank God their weren't any. I made a mistake and owned it. But at the same time, I feel as though I wan't COMPLETELY to blame for this error these reasons: 1. vancomycin must be infused with a pump and that the line must be on a pump when the bag is hung. The RN did not attach a pump to the infusion line or on the IV pole. The nurse said it was sitting on the cabinet. 2. At our facility, as I am sure with any other, when you mix a med in a bag of fluids you must attach an orange sticker to the bag indicating what has been mixed. There was no sticker on the bag of fluids indicating any drug had been mixed with it. I know I made a huge error and I am so thankful it did not harm the patient. But am I wrong in thinking there were other aspects to this as to why the error occured?

[Been there,done that, ASN, RN]

The R.N. made the error by not labeling the bag. There was nothing for you to see. I would have done the same thing you did. You already threw yourself under the bus, don't be so quick to do that in the future. The outcome of the incident report should be very interesting.

[Sour Lemon]

Regarding the unlabeled bag, there's something else to look out for. I've seen patients "reconnected" to IV lines that were not theirs to start out with. It can be near the patient or even hanging from the patient's bed. That doesn't mean that it's not leftover from a discharge or meant for a different patient nearby. So, there's one more thing to worry about in case you weren't already worried enough.

[brownbook]

"I immediately called my supervisor to let her know what happened. I also filled out an incident report. I monitored the patient for any adverse side effects for the duration. Thank God their weren't any. I made a mistake and owned it."

A) You did the right thing. You are to be commended for this.

B) We are making assumptions about some of the details of what happened.

c) Your manager, the pharmacy, nursing education, whoever monitors med errors should investigate how or why it happened, and how to prevent future med errors like this. No one assigns fault, blame, or percentages of responsibility.

[Neats, BSN]

Ok here is my take on it. When administering medication I as the nurse who is physically administering the meds is responsible. There maybe other surrounding issues but it is up to me to check those out and look at the medication, route, dosage...it does not matter what is sitting on the bedside, on the cart or wherever, as a matter of fact you saw the bag sitting there you had another chance to check to see if all is correct....just saying. Administering medication can be life or death you are lucky this resulted in life.

My nursing instructor hit me upside with a ruler one time after I said well it was just Vitamin C. This was my first medication error. This patient was allergic to everything under the sun and I missed the megadose Vita C ordered. When I finally found the order written in a progress note while the nursing instructor was waiting for me to find it, I said well at least it was only Vitamin C. It does not matter what it was for it could have caused grave results. I will always remember that.

[Orion81RN]

remotefuse, I am not in any way saying I am not responsible for this. I made a huge error and will gladly accept any and all discipline for what I did. I am simply making a point that there were other factors involved.

And that is smart of you. It is imperative to look at every aspect that leads to a med error. I look at it like a morbidity and mortality meeting how they look at ever since aspect that lead to an error so each person involved can learn from it.

While you are mostly responsible for this error, the RN needs some education on her part in this. Such as no sticker on the bag. This will be a good learning experience for you. You administered a medication without doing your 3 checks. I'm sure you will be extra careful in the future.

[ffooxx]

I disagree...yes, the OP is responsible but so is whoever prepared the vancomycin and did not label the bag, that's an even bigger mistake, in my opinion. How was she/he supposed to check the medication if the bag did not have any identification/label on it and looked like a regular bag of fluids?

[brockclan3, LVN]

I spoke with my supervisor today and she told me I would get written up for it which is justified. I will also be meeting with our education coordinator later this week for remediation, which I need. I appreciate you all allowing me to be a sounding board for this as well as all of the great advice you provided. I know this will make me a better nurse.

[Sour Lemon]

I spoke with my supervisor today and she told me I would get written up for it which is justified. I will also be meeting with our education coordinator later this week for remediation, which I need. I appreciate you all allowing me to be a sounding board for this as well as all of the great advice you provided. I know this will make me a better nurse.

You're obviously a conscientious person capable of learning without being scolded like a child. Your supervisor is annoying and anger-inducing.

[mtmkjr, BSN]

I spoke with my supervisor today and she told me I would get written up for it which is justified. I will also be meeting with our education coordinator later this week for remediation, which I need. I appreciate you all allowing me to be a sounding board for this as well as all of the great advice you provided. I know this will make me a better nurse.

I hope the RN was also written up for her part in the error. She needs to meet with the education coordinator for remediation as well.

[Kooky Korky, BSN, RN]

You are 100% responsible for this error. You connected the IV and started a medication without checking the bag. There is never a scenario when you don't check a medication before giving it. It takes 2 seconds. It could have been literally anything. You are not owning your mistake if you're saying you are not the only one to blame. You are very lucky your didn't cause any harm, or AKI or anything.

Even if she had looked at the bag, and she absolutely should have, there was no label on it to alert her or anyone else that there was anything in the bag except the IV fluid.

OP, are you IV certified? LPN's can't do IV's at all in many facilities unless certified.

I'm glad there were no apparent bad results.

[Sour Lemon]

Even if she had looked at the bag, and she absolutely should have, there was no label on it to alert her or anyone else that there was anything in the bag except the IV fluid.

Did the patient even have an order for that particular IV fluid, though? If not, it would have been a medication error even if the vancomycin hadn't been added.

[iluvivt, BSN, RN]

I restart IVs all over the hospital in every department.If an IV is infusing when I enter the room I always resume it but I always check everything and I mean everything,including the the tubing change sticker.Then I always call the nurse..tell them I restarted the IV, resumed XY and Z and any other pertinant information.In your case I would have probably done the same thing and resumed the fluids but with one differnce and that would have been a quick communication with the primary nurse.Then it gives you a chance to at least stop an error. I do agree that the nurse who added the vancomycin and failed to label it made an error and is at fault here as well!