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.

[hjfrn]

I know... whoever someday comes up with IV tylenol or motrin, is going to be very rich! that would be such a good medicine.

In the UK we do have IV paracetamol (which is acetaminophen-tylenol) and it is fantastic! Just waiting for Iv motrin

[jimthorp]

what's the equivalent in milligrams to the 1/16 gr. that the pt. received?

That depends on what conversion factor you use. I was taught that gr I = 60mg. The National Weights and Measures Lab considers gr I = 64.79891mg. Therefore, the larger the ordered dose the larger the difference.

I had this discussion with my professor but she insisted that gr I = 60mg was accurate. I disagreed but did it her way.

[BeenThereDoneThat74, MSN, RN]

error waiting to happen: res. has liquid potassium and lactulose in very similar containers. at first glance you couldn't tell them apart. kcl(7.5ml), lactulose (45ml). can you imagine if they got mixed up?

actually i'd prefer to give (or get, for that matter) 7.5 ml of lactulose over the 45ml of k!!:chuckle

[BeenThereDoneThat74, MSN, RN]

in the uk we do have iv paracetamol (which is acetaminophen-tylenol) and it is fantastic! just waiting for iv motrin

can you send some of that over here? i'd be the hero of all my patients!!!

[DR2004RN]

We give potassium IV through a peripheral line all of the time. We long line it so it dosen't burn and give it slowly(over 1hour) We have not had any problems.

I have also heard to never give vistaril iv. Another nurse told me that it crystallizes in the blood stream? Has anyone ever heard of that?

I learned a little lesson when I was a CNA through an RN's mistake......never forgot it. This RN went into a patient's room who was completely blind, but mind was fully intact. Apparently, this nurse equated 'blind' with 'confused'.....at least she said she THOUGHT the patient was confused. She went into the patient's room with insulin (the patient was diabetic) and told the patient she was there with her insulin. The patient told the RN she wasn't on insulin. The nurse gave the insulin anyway, thinking the patient was confused, THEN went to check the MAR!! Guess what?? The patient was NOT on insulin, she was diet controlled. So this RN went to another RN, casually told him her mistake, and asked, "Is this bad?" lol Patient ended up fine after the other nurse called the MD to get a drip going, but I learned to ALWAYS double check my MAR or MD order if the patient questions it, even if they are confused!! And yup, I've stopped errors before because of it.

Also:

* Insulin gtt mixed by a nurse at night-she accidently mixed 100cc NS with 1000 units of insulin instead of 100........patient was found unresponsive, but ended up okay.

* Just the other day saw someone run KCl 20 mEq in 50cc bag through a peripheral line.

* Had patient come up from CVICU with blood running.......blood was not running with NS, but with bag of MVI and Mg. (The RN truly thought we were ridiculous in writing her up for it too!)

* Patient transferred from another hospital was NPO for testing at our hospital. Now, when this patient was admitted to the other hospital he had a BP of 250's/120's.........and was quite difficult to control. Guess what they held that morning he was transferred because he was NPO?? ALL his BP meds!! He had a BP of 240/100's when getting on the ambulance, they gave him IV Morphine for pain, but not his BP pills!

These are just a few, fortunately I've never seen an error that killed a patient, and I hope I never do. I did learn from all these things which I'm actually pretty thankful for! :)

[colter517]

So far in 3 years the only errors I've seen were incorrect narc counts, not on my time.

[BeenThereDoneThat74, MSN, RN]

I have also heard to never give vistaril iv. Another nurse told me that it crystallizes in the blood stream? Has anyone ever heard of that?

Haven't heard of that, but I give it IV frequaently. Never had a problem (though admittedly, I've never checked the bloodstream after :chuckle ).

[lpnstudentin2010, LPN]

You are right. Each pt must be looked at individually.

I was generalizing.

But many times Blood Products are wasted.

I have seen it time and time again. Many Pt's who have suffered blood loss due to surgery actually do better if not transfused. The body is working so hard to accomadate all the new antibodies after a blood product is transfused that is actually slows the healing process. Some Doc's argure that a couple of days of O2 is actually better than transfusing.

There are many Pt's with disease processes that and transplant pts.

truely need blood product transfusion

I had surgery this summer and i had 4 units infused. i was still getting dizzy for 6 or 7 weeks.

[gr8rnpjt, RN]

A male nurse I worked with gave IV dilantin in the wrong dosage, then went to lunch. When he came back the patient was dead. This guy had the nerve to give an inservice a couple months later about dilantin and why we should never give it and run to lunch. What an idiot.

[BeenThereDoneThat74, MSN, RN]

a male nurse i worked with gave iv dilantin in the wrong dosage, then went to lunch. when he came back the patient was dead. this guy had the nerve to give an inservice a couple months later about dilantin and why we should never give it and run to lunch. what an idiot.

maybe that was part of his 'remediation'?? if not, maybe he felt the need to share his mistake with others, so as to not let it happen again.

[TEMPNURSE]

I have to admit that I feel kind of weird writing my first post ever on the worst mistake of my career....

Anyway I once brainfartet in late shift during training, when a new admission to the ward needed to get some heparin as prophylactic. Syringes were not labeled and usually prepared by the early shift waiting in the fridge for patients bedtime (1 ml indicating 5000 i.e. and 1.5 ml indicating 7500 i.e.).

What I think happend was that I ,as before mentioned, brainfarted, not realising that I was not taking Heparin into that syringe, but Insulin (Actrapid). At least this is what I figured out with my Nursinginstructor afterwards.

So what happened was that I injected 60 i.e. Actrapid s.c..

We caught the mistake when we found the patient desorientated and sweating. I took her Blood sugar and It read 24 mg/dl. She was given loads of Apple juice with extra sugar and it didn't get better, so we started to stuff her with sweets and breed and the on duty doc gave her a g5 drip. It took the whole night until the effects were wearing off. Patient was fine , I was devastated close to quit the training alltogether.

What saved me was that the patient was a nun from the order that ran the hospital and she was also the counselor for us nursing students.This incident never left confines of the ward, and I don't think it should have. Of course today everyone prepares his own syringes, and I label any syringe by copying

the names directly off the containers Label also indicating the solution and patients name, I also never use charts were sombody else has written down which patient gets which medication.

Furthermore I don't think that it was a newbies mistake and since that stuff might happen to anyone at anytime I am glad I am now aware of the necessity for personal and systematic safeguards against routine.

We all mess up, but some of us are lucky enough to work with people that prevent the worst from happening.

[irish_std/n]

In the UK we do have IV paracetamol (which is acetaminophen-tylenol) and it is fantastic! Just waiting for Iv motrin

Yes this was just introduced into my hospital here in Ireland. Its apparently super expensive and we have been warned to only use it where absolutly necessary....lol