Med Errors: Share Your Stories

Ruby Vee, BSN · Feb 14, 2009

i'll share! (you knew i'd have stories, right?!)

years ago, when i was brand new to icu and just off orientation, the policy was to change all iv tubings every 48 hours. i hadn't been off orientation more than a couple of weeks, and i had a patient on a nipride drip whose tubing was due to be changed. (nipride, for all you non-icu nurses out there, lowers the blood pressure drastically and immediately. fortunately, it's very short acting.) we were using the patient's hickman line to infuse her drugs, and like the good little hematology nurse i had been up until a few months before, i flushed that hickman with 10cc of ns every time i opened it up. this was no exception. only problem was, i didn't withdraw blood (and nipride) first. so i ended up pushing in a bolus of the nipride that was sitting in the hickman.

oh boy! patient's eyes rolled back and she stopped telling me a story about her children and dfo'd on me. (for the uninitiated, dfo means "done fell out.") she was incontinent, unconscious and the monitor was screaming at me. when i looked up, the art line had such teeny tiny little blips on it i couldn't tell if there were blips. i just about became incontinent of stool! crap! what do i do now?

i had about ten seconds of pure and utter panic before the charge nurse came flying in, having seen the art line on the central monitoring station. in just a moment, her practiced eyes took in the entire situation: me with all the paraphenalia of a tubing change arrayed around me -- i had not yet learned that neatness is a sign of an orderly mind -- and the patient who had been walking and talking suddenly doing neither. "oh," she said calmly. "changed the nipride drip, did you?"

terrified, i admitted that i had. "help!" i bleated. "how do i fix this?"

"don't worry," she said. "she's coming around already." and sure enough, the patient was groggily moving about and the art line pressure was once again beginning to register.

afterward, i was a basket case. the charge nurse sat me down and told me that we all make mistakes, the caliber of the nurse is determined by what they do after they've made a mistake, and that she was sure i wouldn't make that particular mistake again. that was in 1983. i haven't made that particular mistake again, but i have made some doozies.

share your doozies, please!

Ruby Vee, BSN · Feb 14, 2009

in the spirit of sharing, i'll tell a story about another kind of nurse -- the kind i don't want taking care of me.

i was rather new to the city and working in a cardiac surgical intensive care unit. i was spending a lot of time with a nurse i'll call maria, who was also new in town and new to the unit. we were working night shift, and at 0-dark-thirty, maria's post-op cabg patient's pressure tanked. we'd given a fluid bolus and called the surgical fellow, just like we were supposed to do. we'd turned up the pacer, but the pacer was only capturing intermittently and the blood pressure was in the toilet when the surgeon whom i'll call andy arrived.

"give a cc of epi," he ordered catching sight of the amp of epinephrine in my hand.

i handed it to maria who was closer and knew the lines (it was her patient, after all) and repeated "andy says a cc of epi."

maria slammed in the whole (10cc) amp of epinephrine. immediately, the patient's pressure was 290/150 (or something equally unbelievable), and the heart rate was in the 200s.

"what did you give?" demanded andy.

"what you said," answered maria.

"i said give 1cc," he said. "that would be a tenth of that amp. how much did you give?"

"i gave what you said," she said.

meanwhile, i'm feeling something warm and wet on my shoes. i look down, and both chest tube cannisters (capacity of 2 liters each) were suddenly full and overflowing. there was blood everywhere!

we opened that poor man's chest, gave him a ton of products and rushed him off to surgery as soon as a surgical team could be called in. but nothing we did was enough. and maria never, ever admitted that she'd given the whole amp of epi. she kept her job, miraculously, but she lost my respect. and she lost andy's respect and the respect of almost everyone who was there that night. we were never friends again after that.

Melinurse · Feb 14, 2009

i'll share! (you knew i'd have stories, right?!)
i just about became incontinent of stool! crap! what do i do now?
share your doozies, please!

omg ruby. when i read this i about snorked my chocolate milk. lmao!:chuckle

ok , mine was on a post-op total knee replacement. i was still precepting. anyhow, my preceptor had the patient the first 4 hours of the shift. but had only done assessment and the admit. so i came in and took report from her. patient is alert & oriented x 3. so i do an assessment and talk to her briefly. then i go to the chart with my preceptor watching me. she's a brittle diabetic on an insulin drip too. so i get her 2000 meds together that my preceptor should have given her but hey all is good. it is now 0030. i show her i am checking for allergies and point in the chart to all the places we would find a list of patient allergies. she says good job and i start getting her meds together. preceptor even asks me questions about the meds and how they interact together,etc.

so i go into her room and tell the patient what i am giving her. i swear i told her the name of each med!!!! patient said nothing! an hour later i have time to sit and read through h&ps and chart. well, there in the h&p not even in bold is a list of allergies. of course i just gave her a med she's allergic to!!!! hello. so i called pharmacy asap ( did not bother to tell preceptor but was heading towards the patients room to check on her. i notified pharmacy , assessed the patient who was fine, wrote a medication varience form. somewhere in all this i did tell my preceptor. she reamed me a new one for it. yeah, it was nowhere on the chart in any usual places. dang woman knew and even admitted she knew i gave it to her. what the heck. anyways, i monitored her like crazy all night and was so tore up about it. i beat myself up so bad. i was off for 3 days and when i came back, i found out that she was not allergic to the medication just got really bad muscle cramps and nausea from it which were expected side effects.

of course there are others but this one stood out because i was precepting. i think it was in my first or second week of orientation.

Melinurse · Feb 14, 2009

Thank for starting this thread Ruby I hope new grads will learn alot from all our experiences. :yeah:

cloister · Feb 14, 2009

I've done the nipride thing, too, Ruby, on a neuro patient. Wow.......it's dramatic, to say the least!

Where to begin? Most serendipitous would be the one where I had 10 patients and needed to give morphine IM to a 28 yo post-op abdominal surgery. The med nurse had the MAR - yeah, good 'ol team nursing!, it was just after change of shift, and my patient was in pain. A quick glance at the narc sheet indicated that none had been signed out in the past little while, so I drew up 14 mg MSO4 and proceeded to jab it in my patient.

I'm coming out of the room when the med nurse sees me.....with the syringe.

"What did you just give?" she asked.

"Morphine. 14 mg." I replied.

She visibly blanced. "I just gave 10 mg in there 15 minutes ago."

Great.....24 mg morphine in about 20 minutes. Of course, I notified the resident and monitored her respirations like a hawk for the next several hours, kicking myself good for NOT CHECKING THE MAR. The patient actually thanked me when she found out what happened - it was the most pain relief she'd had in awhile. Thank God she was 28 and had been on percocet for a year.......

One that still haunts me? Mixing a pentobarb gtt in 500 cc NS as opposed to the 250 cc NS I was supposed to use. I was 23, taking care of a very critical 16 yo head injury and this was our Hail Mary attempt to save this kid. I double checked it and everything, but neither I nor the nurse double checking me noticed the wrong fluid amount. To make matters worse, I failed also to notice when his pupils finally began reacting, thinking that it wasn't possible on a barb gtt. Day shift caught the error at 6:45 a.m., to my absolute horror.

I came back to work that night only because I was more afraid of what folks would say behind my back than I was about what they'd say to my face. At least one resident told me not to worry about it - it had been three days and they were going to d/c it anyway.

The kid? Made it out of ICU, and walked out of the hospital 7 mos later. I caught an article in the hospital newsletter sometime later that attributed his recovery to.....wait for it.........the pentobarb drip. Needless to say, I ain't buying it.

There are others - oh, my! - but those two leap immediately to mind.

And Ruby, I agree 100% with your axiom: Any nurse who tells you she has never made a med error is either too new to have done it YET, lying through their teeth, or too stupid to realize the error. There are no other options.

CathyLew · Feb 14, 2009

Great thread, and true. No nurse should be cocky about med errors. whenever I make one, I become super careful. You go back to all those checks and ballances that are in the sysem, and you just get so busy, you forget.

we still hand write our MAR's. So most errors are transcription errors. And without an automated drug dispensing system, it is easy to *Borrow* a med from a different patient drawer to give if your drawer is short. we have had transcription errors go on for days before someone catches it.

but even if it is a Colace transcribed as TID instead of BID... when you trace back the chart and find out it was you that did it, your heart skips a beat, and you go all clammy. a horrible feeling.

BabyLady, BSN, RN · Feb 14, 2009

THIS IS A GREAT idea for a thread.

Those of us getting ready to graduate...heck, even still in school, can benefit from the mistakes of others.

Wonderful Idea. :yeah: :yeah:

diane227, LPN, RN · Feb 14, 2009

In 30 years I have only made two errors. 1. I placed ear drops into the eye instead 2. I gave Librium to the wrong pt. That is about it.

Pepper The Cat, BSN, RN · Feb 15, 2009

One morning after a long night shift I hung all my IV antibiotics - and forgot to turn on the secondary line on EVERY SINGLE pt - at least 6 pts. Luckily, days caught my error and all the pts got their meds. To this day, I do not leave the room until I see the secondary line dripping.

Another time I gave Tyl #3 instead of Tyl #2 - just as the pt was swallowing it hit me, those pills were the wrong colour! I almost yelled "spit it out! spit it out!" but didnt' as it was too late. Pt fine - nurse needs a valium!

1776patriot · Feb 15, 2009

I work in LTC resource for a large retirement community where there are about 20+ slots to fill between 4 buildings with Nursing and Assisted living. One night I was at an unfamiliar place that I had not worked in quite some time. It had patients with very similar names. One was named Betty Namer and the other was Elisabeth Namer who lived 3 doors down. Now half the old ladies name Elisabeth were called betty. I gave oxycodone to the patient that was supposed to get hydrocodone. I just about crapped myself when I discovered my error a few minutes later when I got to the 2nd betty..... Patient fine, nurse in panic.

Tweety, BSN, RN · Feb 15, 2009

Busy busy morning, I had a flush and a syringe of 50 mg of Phenergan in my hand, the Phenergan had a different needle to clue me into which was which. Running to give the medication to the patient, an agitated and demanding patient screamed at me to fix the beeping IV. So I stop in my tracks and go to his room, listening to his rant. It was occluded so I decided to use the flush in my hand to flush the line.

To my horror I flushed the line with the Phenergan. The man slept for hours, was elderly and couldn't handle that much phenergan. I was devastated. This was about 15 years ago and I learned some hard lessons. To my knowledge I don't think I've made a med error since.