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?

[brockclan3, LVN]

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.

Yes, I am IV certified.

[bgxyrnf, MSN, RN]

The bag was 500ml. I did not know what the IV rate was to be set at. I mistakenly thought the fluids were just basic NS.

Well, what was ordered?

Even if it's a 500cc bag of NS, you can't assume that it should be run wide open unless you (a) know the clinical picture and have the expertise to know that the doc is going to order it, or (b) said order is in place.

~~~~~~~

Were I to apportion culpability on a 1-100 scale of egregiousness, I would make it 75-25 with the larger share going to the nurse who reconstituted the medication without labeling the bag. There really is no excuse for that and is a 'never event' in my book. On the other hand, though, you had absolutely no business administering any medication without verifying the order and the medication.

[Have Nurse, ADN, RN]

Well done to you for trouble-shooting this unfortunate situation. You won't make that mistake again. And yes, you are right to think that more factors played a part in this.

[peachtreednurse, RN]

"I did not ask the RN or even think to check the bag" The KEY points in this statement are I DID NOT ASK, OR EVEN THINK...Banish those two proclivities from your practice and you'll be less likely to find yourself looking to take someone down with you. The R.N lucked out because you made the mistake of assuming the care of a patient you knew nothing about...She may have been interrupted by Radiology or pulled away prior to Radiology arriving for the patient and would have been prompted to complete everything as ordered had you ASKED FIRST!

[peachtreednurse, 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.

Admitting that you would take the same action as the OP is one of the reasons health facilitators place so much emphasis on the collection and evaluation of incident reports. With this actual report system review of markers the reports have in common, can come under closer evaluation, and other steps put into policy to prevent imprudent action.

[AnnieOaklyRN, BSN, RN, EMT-P]

Why was the Vanc not on a pump, or was it???? Medications that cannot be boluses should never be unhooked from the pump and just left attached to the patient, this is asking for a med error. This happened to one of our EMS crews who transfer patient who required IV Heparin. Once they got to the ER the nurse hadn't come in so they took the Heparin off their pump and left it attached to the patient, and another staff member, they are unsure of who must have assumed it was just fluid and boluses the ENTIRE bag of Heparin into the patient (who was suppose to have surgery) in only a few minutes. Never ever do this!! Also your biggest mistake was not looking at the bag, always triple check your labels, and if it isn't your patient ASK THE PRIMARY NURSE FIRST, and never assume.

Learn from this and move on from it.

Annie

[AnnieOaklyRN, BSN, RN, EMT-P]

No, KrysyRN, there was no label. It looked like a bag of regular fluids. I am a support for the RNs I work with by helping them with their tasks; documentation, giving meds, starting IV's, ect...tech stuff. This creates a whole new aspect for me when it comes to patient care. I thought I was doing the right thing but ended up potentially harming the patient because of it.

This is an even bigger error in my opinion, how can you label a bag you have lost site of?! How do you even know its still vancomycin, and someone didn't switch the bag of fluid for whatever reason. This RN needs to be reprimanded more than you do, and to not have it even on a pump is worse in my opinion!!

Medication labels need to go one before the medication is even connected to the patient, not after!

Annie

[amzyRN]

Everyone makes mistakes. Admitting to it and taking responsibility involves reporting it and talking to the doctor to make sure any follow-up needs to be done. I wouldn't let it sink my confidence but would use it as an opportunity to grow and improve. Also, someone mentioned that the bag should have been labeled and on a pump, if it wasn't that's a med error too, so filing an incident report will help improve safety on your unit. The RN contributed to the error by not labeling the bag and not having it on a pump.

[brockclan3, LVN]

Just an update: I was asked by my supervisor to not clock in for my regular shift but instead meet with her and HR later in the day. This isn't good...what should I prepare for?

[peachtreednurse, RN]

Believe me, I don't want to scare you or hurt you more than you are hurting already, but it may be a probationary/written warning type of situation. I would not defend my actions but rather own up by getting specific about the potential for harm that existed in the situation in plus a few additional scenarios expressed by you, and how relieved you are nothing grave befell the patient, and how certain you'll be about instituting the 5 R's...

[brockclan3, LVN]

That is great advice, peachtreednurse. I am nervous as heck. Preparing for the worst, hoping for the best.

[JKL33]

Whatever it is has likely been decided. My opinion doesn't count for jack, but your participation in this discussion makes me hope they will give you a second chance.

I wouldn't talk much at all unless you are asked questions for the purpose of them making decisions based on the discussion you're having. IF you are called upon to speak before you know what's going on, then yes, tell them that you have reviewed in detail the portion of this where you went wrong - be brief but specific: "I understand that every instance of hooking a patient to medication or in any way administering medication, including saline, must be accompanied by the 5 Rights of medication administration." Then state something like, "I would ask for the opportunity to demonstrate that I have reviewed my errors in thinking and the proper steps of medication administration, and that I am capable of being a safe and helpful member of the team" (through following policies/protocols, critical thinking, and excellent communication).

Try to stay in professional mode rather than rambling on and on in self-deprecation mode. They'll want to see acknowledgment, strength, determination, and commitment.

Do not bring up the RN/Vanco. You are involved in this only because you hooked a patient to medication when you had no idea what the orders were. If they bring up the RN/Vanco, say, "Yes. But I should have known what was ordered for the patient."

If they do anything other than end your employment (such as if there is to be probation, etc., etc.) I would probably let them know you appreciate it.

Sincere good luck to you ~