med error panic

[vaccinia]

I'm a new RN working on a surgical floor. I'm still in orientation & working with an excellent, experienced preceptor. Yesterday we had a patient with a long history of IV drug abuse admitted. He had IV Ativan ordered, and over the course of the shift I gave him three 1 mg doses. As I was leaving, I noticed the next nurse preparing his Ativan by diluting it with NS. My preceptor had already gone, so I went home and looked it up (which of course I should have done before I ever ever gave it b/c I've never given IV Ativan before) and of course it says to dilute. I showed my preceptor all 3 doses (1/2 ml, obviously not diluted) before giving it each time and she watched me walk into the room with it. I gave the small amount very slowly (over 3 minutes) because it was viscous. Pt's IV line was still patent at the end of the day and he said the site was not painful. What should I do now?

[traumaRUs, MSN, APRN]

I would discuss the issue with your preceptor. You may need to go further up the chain of command. I would certainly use this as a good learning experience - always check meds BEFORE you administer them.

[bklynborn]

that stuff is so thick i am trying to figure out how you were able to draw it up and administer it without the ns

[Tweety, BSN, RN]

What you should do now is learn from your mistake. The time to look up a med is before administration, not after.

Do you have an IV Drug book? That was indispensable to me until I learned the various meds I was given. Some are diluted, some aren't, some have slow rates of administration, and some don't. Slow down enough to look up your IV meds and learn. Soon you won't have to look them up.

Definately talk it over with your preceptor what you have learned.

[SuesquatchRN, BSN, RN]

Don't panic. Luckily, there was no harm, no foul.

Talk to your preceptor. And as Tweety said, definitely look up all of your IV meds before administering.

[kstec, LPN]

I'm a LPN with minimal IV experience,but I do know from working in pharmacy for 15 years that if it was flushed with saline afterwards, no harm should be done. I would call the pharmacy and clarify, but I remember getting call regarding pushing non-diluted meds and the advice was to make sure the line was flushed afterwards. If I'm wrong I apologize but that is what I learned working in pharmacy.

[neneRN, BSN, RN]

I really don't think giving that dose of Ativan undiluted is a big deal.

The recommended dilution for Ativan is 1:1 with normal saline, so the dose you gave really only called for 1/2 cc of saline to be added. You stated that you had pushed it over 3 minutes...IMO, pushing it that slowly really ends up having the same effect as diluting it would have, as pushing a 1/2 cc over 3 minutes would result in a very tiny amount of the med hitting the circulation each second...think about it, that's like giving 0.16 cc over a minute and the normal circulation of blood is more than enough to dilute that miniscule amount of med passing through. (If the pt had IVF running as well, then you don't need to dilute)

I've given Ativan many times without diluting it, to pts with active seizure activity. I have seen probably all of my co workers do it as well. In these instances, it's just pushed in, and not slowly. (this is in the ER where its given very frequently) I've never seen it cause a bad outcome or ruin an IV site. (Obviously, I wouldn't try this on a little 90Y/o with a 22 in the hand!)

No, I'm not advocating going against the recommended administration for most meds! My point is that it is very unlikely that you caused this pt any harm.

My only concern is that you did not look up a med you are unfamiliar with; you need to look up any first time med before you ever even draw it up. ALWAYS! No, this time wasn't a big deal, but there are many meds that could have very severe adverse outcomes if not given properly, and you are lucky that this wasn't one of them.

[AnnieOaklyRN, BSN, RN, EMT-P]

hi,

I agree that there was probably no harm done, especially if the patient had IV fluids running. Just remember, you do NOT dilute Ativan when giving it IM.

Also I agree with the others, always ALWAYS look up those meds before you give them (no matter the route), even if you are with a more experienced nurse, as he or she may just assume that you are already familar with the med. If its an emergency let someone else who is familar give it. There is no exuse for giving a med that you have not looked up and remember if an error occurs it is no fun to live with it, especially if it causes harm.

I am a new grad that is only 2 weeks into working as an RN and I can understand what a pain it is to have to look up lots of drugs, but it is well worth not killing someone and protecting your license. I also know if you have a preceptor that is rushing around it can feel awkward having to put the breaks on, but don't be afraid to be honest and let them know you need to look up the med, they will be happy you are being safe. Also if you have a free moment ( i know,not likely), but if you do take the time to look up those meds instead of waiting till its time to give them.

good luck

Sweetooth

[vaccinia]

Thank you so much for your responses. I will talk to my preceptor on Monday. I was very nervous about this pt. in general because he has a recent history of stealing from our hospital, and was recently released from jail. I felt pretty uncomfortable with the whole thing. My inexperience and worry about the situation clouded my judgment-- I have looked every other drug up in my 6 weeks of orientation so far. (So I think there's hope for me)

Thanks again.

[luv2yoga]

When I was doing my senior preceptorship, I was told to dilute every single IVP as a rule. Don't give anything straight. Those of you with more experience, tell us if this is a reasonable rule.

[vaccinia]

One more thing-- the pt did have IV fluids running (D5 1/2NS) at the time-- does that count as dilution?

[deeDawntee, RN]

Don't panic!!! You are OK. Our Ativan comes in Carpujects and I have never seen anyone dilute it in our institution. One of my drug books say to dilute it and another 2 sources do not. I will bet that your preceptor does not dilute it either, she may have come from another institution where that was not the protocol.(?)

On the other hand, as a new nurse, you should probably have been aware of the practice and asked about it. But please don't beat yourself up about it. Very good lesson because there will be no consequences to the patient. I would ask your preceptor or even one of the pharmacists what drugs need to be diluted in your institution according to protocol. Because there will be differences from place to place. Also, if there is no where to document that it was done, it often is left up to nursing judgment, but that is also something that you should clarify. If it IS a part of your facility's protocol, it should be on the MAR, and if not, I would say that your "error" is in a big part a system error and should be handled as such, (in other words, they need to institute instructions on the MAR to say to dilute it and with how much NS etc etc etc)

What is more important than dilution, is the drugs that you have to give slowly...like Lasix, Toradol, Phenergan, Diltiazem boluses....etc..to name a few....those drugs can be a lot more dangerous than any I can think of that are supposedly supposed to be diluted.

Let go of it...give yourself a break...if that is the worst thing you ever do, you will be well ahead of the game...we all do stuff...believe me...and if anyone makes you feel bad, they are not being supportive or honest about their own mistakes.

I would say that IVF's do count as dilution, in my own nursing judgment and practice, but it may be another thing you want to clarify. Hey, you are going to be great!! You are asking all the right stuff!!!