Med Errors

[UM Review RN]

For our collective benefit, list some of the med errors you've seen committed or caught before they were committed.

The only rules are:

1. No blaming.

2. No naming names.

3. State what the error was.

Examples:

1. Mag and KCl hanging without a pump. ---Both need to be administered on a pump.

2. Regular insulin, pulled up in mg's, not units ---Self-explanatory.

3. Digoxin 0.125 mg po qd ----Given with an apical HR of 42.

4. Order for Vistaril IV ---Never give Vistaril IV.

5. Lopressor 25 mg po bid, 1 tab ----Pt. got 50 mg. because this med only comes in 50 mg tabs and should've read "1/2 tab."

6. PRBCs hung over the 4 hour limit. PRBCs piggybacked into ABTs. ---PRBC total hang time may not exceed 4 hours. This might include time taken from the blood bank in some facilities. ---Never piggyback anything into PRBCs.

7. PRBCs not hung for over 24h with a Hgb of 6.8.

8. "Demerol 100 mg. IVP q2h prn" --Classic case of "too much, too soon."

9. "Percocet 1-2 tabs po q4h prn, Darvocet N-100 1-2 tabs po q4h prn, Tylenol ES gr. X q4-6 h prn" ---Tylenol can potentially exceed 4 gm/day max.

10. Dilantin piggybacked into D5. ---NS yes, D5 no.

[UM Review RN, ASN, RN]

This is unbelievably SCARY and TRAGIC!!! I myself am a nursing student in my first semester of clinicals. That said, I must ask: what are PEG meds and what is CVC?

PEG is an acronym for a percutaneous endoscopic gastrostomy. We also call them G-Tubes.

It's quite large and usually if a patient has a PEG, they're NPO (nothing by mouth), so the medications are crushed, mixed with a little water, and after dissolution, poured into the PEG tube and go right into the stomach.

Here's an interesting article with a picture for you:

http://www.permiangi.com/patienteducation/epa/peg.html

A CVC, on the other hand, is a Central Venous Catheter. This one doesn't go anywhere near the stomach. It threads in through a vein to the upper chamber of the heart. Any Central line will END in the heart. You'll see them in the upper arm, the neck, or the chest. You can usually tell the difference between a central line and a peripheral line. But you must always look in the Patient's chart to know for sure, because there are different types. Hint: if you really need to cut to the chase and find out what your patient has, look in the X-ray section of the chart. Central lines really should have their placement verified by X-ray after the procedure.

http://www.medterms.com/script/main/art.asp?articlekey=19698

http://www.photocean.com/images/320.jpg

So what happened in the post above is that the student gave a patient crushed oral medications into a place where only intravenous medications were to be given.

And yes, I agree that the outcome was tragic for the poor patient, as well as the nurse who was fired.

[NotReady4PrimeTime, RN]

We've also had an incident where oral meds were given via central line. A new grad (less than four months in the unit) gave captopril syrup by central line to an infant with complex heart disease who was ready for transfer to the floor. The baby arrested immediately. Lucky for the nurse, the incident happened during rounds and the whole team was at the bedside, so the baby was successfully resuscitated. Shortly after the incident. we were provided with special syringes for use with oral meds that cannot be inadvertantly used with an IV route. But the weirdest thing that happened was that our manager apologized to this nurse for her being put in the position to make the mistake!!!!!!!!!!!! The baby was ready to go to the floor for heaven's sake! And whatever happened to the Five Rights?

[CseMgr1, ASN, RN]

Years ago, I worked with a new graduate Practical Nurse who gave a patient two vials of Dilaudid 'IM'. The order called for Dilaudid gr.1/64 'IM' PRN, and the vials were labeled 1 cc = gr.1/32. Instead of giving one-half of a vial (0.5 cc), she got mixed up and gave 2 cc. Her patient coded, but survived, thank God. I can't say the same for her nurse, who was immediately demoted to an Aide and was never allowed to practice again. It was so scary, and I felt terrible for her. It could have happened to me...or any of us.

[steelcityrn, RN]

Most medication errors I come across are patients taking/mixing medications wrong. Taking their old coumadin with their new plavix, taking 325 asa instead of 81, taking 50 lopressor instead of 1/2 of the tab, which sets them up anyways for a med error. When ever they get their medications from the VA they are almost always white round pills, larger strength that needs cut and poor medication labels that I can hardly read let alone a elderly patient.

[DLS_PMHNP, MSN, RN, NP]

A nurse at our facility gave an infant an injection of Oxytocin instead of Vitamin K...

[ClaireMacl]

Hiya,

I'm confused, so I figure I'll ask! We don't work in CCs, so I don't understand them, but if I seen that the order was for 1/64 IM PRN and the vial said 1/32, I'd think that to get to 1/64 it would mean two vials. Now don't judge me, I know nothing of US medications, but I'd think if it said 1cc = 1/32, that could be correct, where have I missed something? (ps, i don't even know what dialudid is, lol, darned UK). Or, did you forget to say how many CCs there were in a vial?

Years ago, I worked with a new graduate Practical Nurse who gave a patient two vials of Dilaudid 'IM'. The order called for Dilaudid gr.1/64 'IM' PRN, and the vials were labeled 1 cc = gr.1/32. Instead of giving one-half of a vial (0.5 cc), she got mixed up and gave 2 cc. Her patient coded, but survived, thank God. I can't say the same for her nurse, who was immediately demoted to an Aide and was never allowed to practice again. It was so scary, and I felt terrible for her. It could have happened to me...or any of us.

[Morning-glory]

Haldol, on the other hand, can be given IV, according to the drug book--apparently there are two forms of the drug, haloperidol lactate and haloperidol decanoate. Haloperidol lactate, it seems, is the IV form of haldol that has "unlabelled use" as an IV med "in acute situations."

Angie and everyone else...FYI

Anything "Decanoate" is a long acting medication with an oil base used in psychiatric settings. It is given IM Z-trac with a 2 inch needle. I shudder to think what would happen if it were given IV.

[UM Review RN, ASN, RN]

Hiya,

I'm confused, so I figure I'll ask! We don't work in CCs, so I don't understand them, but if I seen that the order was for 1/64 IM PRN and the vial said 1/32, I'd think that to get to 1/64 it would mean two vials. Now don't judge me, I know nothing of US medications, but I'd think if it said 1cc = 1/32, that could be correct, where have I missed something? (ps, i don't even know what dialudid is, lol, darned UK). Or, did you forget to say how many CCs there were in a vial?

That's why you have to do the math and check with someone else. Intuitively, it seems like 1/32 + 1/32 = 1/64, but that's mathematically incorrect, because when you ADD denominators, the denominators stay the same. You'd actually have 2/32 or, simplified, 1/16.

I hope that helps.

PS Thanks for the information, Jacqui!

[Bipley]

Wow. This thread is getting very interesting, Stevielynn!

My drug book says not to give Vistaril IV. It's a Lippincott 1999 ed. (The new one's at work.) I don't have access to the Pharmacist until tonight, but if I get a chance, I'll ask her, because now I'm really curious.

So stay tuned for more on The Vistaril Solution...

(OK, not a great pun, but hey, I tried....) :chuckle

Haldol, on the other hand, can be given IV, according to the drug book--apparently there are two forms of the drug, haloperidol lactate and haloperidol decanoate. Haloperidol lactate, it seems, is the IV form of haldol that has "unlabelled use" as an IV med "in acute situations."

There's also a section in "Nursing Considerations" that states "Do not use haloperidol decanoate for IV injections."

I'm not very familiar with Haldol IV, as we can't give IV Haldol on our Progressive Care unit. Hospital policy states Haldol can only be given IV in ICU areas; the rest of us can only give it IM. (Perhaps we only have the deconoate form in our Pyxis?)

Can *any* deconate be given IV? Don't they ALL have to be given deep IM?

[Bipley]

After a fire (I have asthma) Solu-Medrol 500mg q12h IV push ordered. 500mg given in ED, 2 hours later in ICU another 500mg IV push given. Oye.

[Bipley]

MD ordered 200mcg Synthroid IV qd, RPh entered the drug correctly. Pharm Tech filled it with 200mcg tablet vs. vial. RPh missed it when he checked it. RN crushed tab, gave it IV. Pt okay.

Most amazing med error in my career... resident orders Augmentin 500mg. ICU nurse goes to give it PO. Resident argues and insists IV admin. RN (me) disagrees, Augmentin doesn't COME IV. Resident insults RN, RN insists PO, resident insists IV. RN gets PharmD, PharmD and RN walk into room as resident just finished pushing Augmentin IV. PharmD asks since when are IV meds pink and bubble gum flavored. Indian resident turns amazingly white. Pt okay.

Giving wrong pt antipsychotics (pt sedated but fine), adult dose of Dig given to NICU baby (baby died), hanging wrong IV solution (no problems), then...

We also have pt mistakes. Pt given Rx for AVC vag supps, came back 10 days later with no results, wanted new Rx because they tasted so bad, men using any supp c/o pain with supp insertion. They didn't know to remove the aluminum foil wrapper first. My favorite.. pt called c/o that she couldn't finish a bowel prep for lower GI. Reason... she didn't like the flavor of the enema tip. (that would be KY jelly) Now com'on people, since when does the medical profession give adults a baby bottle of salty solution with a long hard nipple and KY on the tip???

[Bipley]

Whoa!! Thanks so much for that one! I had no idea! I'll keep an eye out (no pun intended ) for that as we seem to get a lot of patients who've recently had cataract surgery and need frequent gtts.

The nurse is very correct. My 10# Shih Tzu has Glaucoma, has had since she was 4 months old. We have learned the horrors of Timoptic. She's been in doggy ICU from chewing up a bottle of Timpotic 0.25%. I also had to give her extra doses for increase eye pressure. I actually listen to her heart with my steth with I have to do this. Amazing what EYE drops can do to the heart.