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?

[peachtreednurse, RN]

Vancomycin given IV too rapidly can cause anaphylaxis...a major reason for the slower rate of infusion. The potential for harm did exist to a greater degree than apparently realized.

[Boston RN]

The negative --> you administered medication without checking the bag (Yikes). The positive --> you'll NEVER do that again! I believe this error will make you a better nurse going forward. Good luck :)