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.

[Mulan]

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 ).

Any literature I have seen regarding Vistaril indicates "not to be given IV".

Can you give your sources indicating that it can be given IV, since you say that you give it that way frequently?

[kids]

Not necessarily the worst, but the longest med error I ever saw was a pharmacy error in a SNF.

At this point in time I can't remember what the right medication was. Patient had been on it "forever", new card came from pharmacy and the nurse noticed that the pills looked different than previous supply. Call was placed to pharmacy and she was told it was the correct med, just a different generic supplier.

Ten days later I worked the section as a float and immediately recognized the pills as 60mg diltiazem. Patient with no cardiac history had been getting 2 tabs BID for 10 days and had been having symptomatic hypotensive episodes.

[LoriAlabamaRN]

When I was in nursing school, I was told a horror story about a relatively new grad losing her license because the order for PRN Percocets read 1-2, it was handwritten sloppily and she didn't see the "-" and gave TWELVE. Fortunately the charge nurse realized relatively quickly when the girl asked her (after the fact) if she had ever had to give that many before... the patient required Narcan of course, and I think charcoal lavage, but survived. The nurse lost her license, and received it back under probation after three years I think...

[kids]

Re: Vistaril

From Medscape Drug Reference:

•Administration

Hydroxyzine hydrochloride and hydroxyzine pamoate are administered orally; hydroxyzine hydrochloride may also be administered by IM injection. Because severe adverse effects may occur, the drug must not be administered by subcutaneous, intra-arterial, or IV injection. (See Cautions: Local Effects.)

•Local Effects

Marked local discomfort, sterile abcesses, erythema, local irritation, and tissue necrosis may occur at the site of IM injection, and marked localized subcutaneous tissue induration has been reported as a result of extravasation of the drug. Following inadvertent intra-arterial injection of hydroxyzine hydrochloride, thrombosis and digital gangrene necessitating amputation have occurred. Phlebitis and hemolysis have been reported following IV administration of the drug. Following inadvertent subcutaneous administration of hydroxyzine hydrochloride, tissue necrosis, tissue slough, swelling, edema, petechial hemorrhage, and abscess have occurred.

[BeenThereDoneThat74, MSN, RN]

Any literature I have seen regarding Vistaril indicates "not to be given IV".

Can you give your sources indicating that it can be given IV, since you say that you give it that way frequently?

I have to laugh (although it's not funny), as i'm reading this rally really really old pst, my name came up in a quote, and i gave that very same med yesteday, via iv. I'll see what i can come up with...

[psalm_55]

After so many years in nursing I feel this way about med errors. Many of them occur only because the nurse is overworked, stressed and rushed...trying to do more than one person can do in the time she has. When another nurse lectures and says 'there's no excuse' I wonder if we work in the same environment. It seems today there is so little support for us on the job, and we are not getting what we need to be successful in the workplace. Like we are being set up to fail so we can be scapegoats.

I feel more and more like the workplace itself today is just a 'mistake waiting to happen', with the workload, short staffing practices, the endless tasks and paperwork, the endless demands. No wonder there is a 'shortage' and so many nurses will not work as nurses any longer.

i'm with you on that!

[UM Review RN, ASN, RN]

Any literature I have seen regarding Vistaril indicates "not to be given IV".

Can you give your sources indicating that it can be given IV, since you say that you give it that way frequently?

Recall the old saying, "What goes around, comes around" ? Because this argument was already done in the first 35 posts of this thread.

So if you have questions, might be best to ask Pharmacy and check your hospital policy on Vistaril before assuming anything.

We still do not give it IV.

[HappyNurse2005, RN]

Pt w/ K of 2.4

MD notified, ordered 40meq kcl in 100cc 1/2ns over 4 h. verbal order transcribed correctly by RN. scanned to pharmacy.

RN calls pharmacy to check if they will be mixing the drug or if she needs to. They say they will.

Pharmacy sends it. in 1000cc 1/2ns instead of 100cc. RN gave the 1000cc bag over 4 hours. to a CHF pt. (pt was fine, btw, no ill effects)

[ICU_JOSIE, MSN, 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?

This is simply a case of fractions my friend, like asking which is greater? 1/2 or 1/4? It's like this, as the denominator gets bigger, think of a piece of cake getting sliced into smaller pieces. Hope you get the picture right.... just trying to be helpful ....

[babiesX2]

The worst med error I've heard about on my unit was Vancomycin given IVP.

[Mulan]

Recall the old saying, "What goes around, comes around" ? Because this argument was already done in the first 35 posts of this thread.

So if you have questions, might be best to ask Pharmacy and check your hospital policy on Vistaril before assuming anything.

We still do not give it IV.

I am not assuming anything. To my knowledge, it cannot be given IV. I was asking the poster what her source was since she stated that she gives it IV all the time.

[UM Review RN, ASN, RN]

I have no problem whatsoever, Mulan, because as I said, this whole Vistaril IM vs IV was already done on this thread. I know because I started the thread.

I was just trying to be helpful.

By all means, if you want to go and have the same discussion again in the same thread, it's fine with me.

Carry on. :)