Med error!!!!

[gettingupthere]

I have a story, there is a lesson to be learned, it was a hard one for an LPN I worked with. A few weeks back, this LPN was giving meds on my rehab unit, we had 2 pts with the same last name. They are sister in laws. We had them on 2 different halls and 2 different med carts.

The LPN was a float on the unit. She knew only one of the residents from the last time she was on the unit. She gave the wrong meds to the wrong resident. There were several different B/P meds, the resident is confused, so didn't question the nurse and took them. The other rsident was programed to say " I'm Mary" when she was approached for meds! We immediatly contacted the MD, supervisor and DON. Started monitoring her V/S every few minutes. After about an hr, the B/P began to drop, we called an ambulance and sent her to the hospital. She returned about 6 hrs later, OK. In the meantime, the nurse who gave the meds, of course was upset! She explained that she knew THAT resident, but didn't know there were 2, even though she sat for report on both sides of the unit, she didn't read her armband. Well, she was fired! Besides being a terrible nurse from day one, there were other med errors in the past. I know errors are made, I have made my share too, but there is always an opportunity to pass a lesson along. More to the story! Almost a week later, this poor woman fell getting out of bed in the middle of the nite and suffered a subdural hematoma! she is back to us once again, but she's just not the same.

[sasha2lady]

man.....we had a very similar story a few yrs back w/ a new nurse....she gave the wrong bp meds to the wrong pt who just happened to be our md's mother in law! how ironic was that one! well...she ended up being ok too but it traumatized the nurse...she got the pt mixed up w/ the one across the hall from her ..they had very similar names...eerie.

[SPNbabe08]

eeek! thats aweful. and they rate med errors according to their effect or adverse effect on the patient.

this is why everyday my teacher tells us that you can never ever be to careful during a med pass

[Starr1966]

i used to work in a hospital on a subacute unit. i came on duty and received patients from a float nurse. prior to my arrival he had administered medications to the wrong patient and some of the meds were bp meds. it was quite scary, the patient was fine in the end, thank goodness! i have made two med errors in my 11 years of nursing and i have learned from them. some may think that i'm to cautious, but i don't think there is such a thing.

i now work in a ltcf and know all the residents. when i first started there i was very nervous about giving meds to the wrong resident. we have pictures of them on the cardex, but they aren't always current and as we all know people change in appearance. i wished they had armbands. i know they don't because this is their home and at home you don't wear an armband. i think it would be a good idea for safety. i also wished that they had armbands or some kind of a coding system on the resident for their code status. its quite hard to remember who is all a code or no code and in an emergency it would be nice to be able to know immediately without having to look in a chart when every minute counts.

sorry for getting off topic a bit.

[gettingupthere]

Actually, the residents in our facility DO wear name bands AND we have pictures on the MAR! Our arm bands have Name, Rm # and if they are a DNR there is a yellow dot on the band. There are things we are NOT allowed to do because it is " their Home", like overhead pageing. I think it's rediculous, when I need a supervisor, I NEED A SUPERVISOR, I don't need to call all over the place or use a walky talky ( that never works properly). A little after note regarding this med error originally pasted about. The state was called, the investigater came in and reviewed the chart, care guide, care plans, MAR for this resident AND the other with the same name. Haven't heard back on the outcome yet! Will keep you posted!

[pagandeva2000, LPN]

We can never be reminded enough about the seriousness of medication passes. What frustrates me, however, is that many facilities have not made things easier by providing the armband or bracelets that can help. I do know that this is the patient's home, however, there are many 'intruders' in this home...float nurses/cnas, agency nurses, new nurses...too many people that can make a dangerous mistake. If I were a family member, or even a patient there, I would be more concerned about receiving the correct medication than I would about having a bracelet that further idenfies who I am.

[jadey1]

We had a nurse, who made a HUGE med error, once. She's no longer a nurse, r/t to this med error.

I'm a float, so I worked that unit the day before. A resident said that she was on a prefilled insulin syring, at home, and that regulated her blood sugar well. At the time she was in our facility, her blood sugar was all over the place. So I passed it on that we needed to obtain an order for Byatta, from our house MD. We got the order, the prefilled syringe came from Pharmacy. No disposable needles came with it. The packaging that the syring came in had "DO NOT DRAW MEDICATION FROM SYRINGE WITH ANOTHER SYRINGE" (or something to that effect). The individual dosage was written on the package, along with "30 day supply." The nurse didn't call pharmacy to double check dosage or search, online, through the manufacturer, for dosing. The nurse took a seperate syringe and drew up ALL of the medication and passed it to another nurse to administer. They injected ALL 30 days worth of Byatta at ONCE! They sharps'ed the syringe and moved on.

On 2nd shift, the following nurse noticed the resident was short of breath, diaphoretic, irregular pulse, VERY low bp, and sent the resident out 9-1-1, with cardiac symptoms.

3rd shift came along and the nurse on duty saw the syring in the sharps container. She fished it out and saw that the med error occurred and notified the hospital and DON.

HUGE MED ERROR! The woman went into cardiac arrest but she came through it. State was notified. The nurses involved were put on suspension, pending an investigation. The one that drew the med up, ultimately, lost her license because she already had strikes against her. The nurse who administered it was also terminated.

5 RIGHTS!!!! We have armbands with names, room numbers, admission date, red dot for DNR, green dots for thickened liquids, and pictures in the front of the MAR. You can never be TOO careful!