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.

[NotReady4PrimeTime, RN]

I made a good catch the other night. We have a toddler who has been on ECMO and CVVHD for nearly two months for adenovirus pneumonitis/MODS. In our unit, ECMO and CVHD are both considered to be extracorporeal life support; our team is made up of roughly 60% RNs and the remainder are RRTs. There has been a transfer of function done to allow the RRTs to mix drug infusions (heparin, CaCL and citrate) and to add drugs to dialysate. All drugs are a two nurse check, or in this case RN/RRT. The ECLS specialist that night was one of our RRTs. He mixed up a bag of dialysate early in the shift, drawing up the KCl and KPO4, labeling the syringes and then filling out the medications-added label while I was busy doing something else. I had checked many bags of this formula and knew the volumes required of each electrolyte. No problems there. Then on towards morning he got ready to mix up another bag. I was sitting on a chair watching, so he drew up the KCl and showed it to me then put it into the bag right away. I turned my head for a second, having seen movement of my supposed-to-be-pavulon'ed patient out of the corner of my eye. When I looked back, he was in the process of drawing up 17 mL from the bottle of KCL, thinking he had the KPO4... which was in a 50 mL minibag. He was mortified when I pointed out that he had the wrong K, but relieved that it hadn't made it into the bag yet. The bag wouldn't have been hung until after we were long gone, and the kid was only on q6h bloodwork, so the rising K+ would have been unidentified for a long time. (Not that it would have really made any difference to the outcome. Poor child had no chance of survival anyway.)

[Michellem0322]

I am just pre-nursing and this thread scares me to death. I know everybody is human and makes mistakes. I know I will always try to check and recheck every med. This thread really does open the eyes of us non-nursing (yet) Thank you

[imahobbit]

as nursing student nearing graduation was in OB rotation doc on ordered 25 mg of STADOL--teacher had drilled never give more than 4mg --- asked twice-doc screamed "I said 25mg STADOL"--did not do..went to RN--she came in to doc and touched her arm and made eye contact and very quietly said "do you really want 25mg Stadol" doc looked dazed and replied "I said 25mg demerol" we left RN gave ordered demerol. I learned a great lesson that day that I have used since--quieter voice gets attention.

[HappyNurse2005, RN]

My almost today:

had a little man getting a colonoscopy today. Order said 2liters of go lytely. My first go lytely experience. So the huge jug is in the fridge. I get it out. I ASSUME that it was the proper size, that he was to get the whole thing.

Well, no. the jug was 4 liters. his dose was 2 liters. the nursing assistant caught it. almost double dosed a little man. oops.

of course, another pt (not mine) had IV bactrim due to them. it comes in a 500cc glass bottle of d5w. same as IV amiodarone. bactrim was at 250cc hr for 2 hours. accidentally given the iv amio. whole bottle infused. (900 mg of amio over 2 hours)

I feel so bad for that nurse, b/c she must really be beating herself up over that. the bottles were identical, except for the pharmacy label. pt went bradycardic/hypoxic/hypotensive, had to be put back on ventilator (was already trached and previously vented) put on dopamine/dobutamine.

[HappyNurse2005, RN]

Argatroban hung as a IVPB and run over 1 hour (nurse didnt know what Argatroban was and assumed it was an antibiotic).

well, i learned something new. i didn't know what argatroban was.

[UM Review RN, ASN, RN]

Found a Zithromax 500 mg IV given by another unit. Zithromax in that amount should be hung with 250 ml bag of fluid to dilute, but this one was found with a 100 ml bag.

[Ann RN]

I worked with a resident who actually did a carotid ABG because the patient was a hard stick! Anyone want to guess the results???

[shock-me-sane]

I worked with a resident who actually did a carotid ABG because the patient was a hard stick! Anyone want to guess the results???

i haven't the slightest clue what that would do to the results. please share.

[Kymmi]

Well...Im sure the result of the ABG was correct when the patient was still alive but Im willing to bet that the patient didnt survive being stuck in the carotid artery for a ABG.....thats really pretty scary and its even more scary to think that when we're sick or when we get older we're going to put our lives in the hands of strangers also.

[htrn]

We keep stock meds in ziploc type bags for patients that come in after pharmacy closes (9pm-7am). Have found Nubain in the Narcan bags, vicodin in the motrin bags, and PNV in motrin bags.

Have seen 100mg demerol instead of 10mg morphine given IM - both are kept in baggies in same drawer and nurse not paying close attention

Motrin given on a schedule 08, 14, 20, 02 - pt. refuses 02 dose but wants it at 04 - then next shift gives 08 dose on schedule because of habit, despite being told in report that it was given at 04

Motrin given while patient on Toradol

After the recent posts on magnesium sulfate ODs and deaths, had a pre-eclamptic pt on mgso4 undergoing pit induction go back for a stat c-section. I made sure everyone in the room new about the mgso4 then I put a piece of tape across the dial and the cartridge door on the pump.

Not med error, but same type situation. 10 babies in nursery (one of our crazyest nights) Two babies being circ'd. Supposed to be done at 08, but doc comes in for delivery and decides to do hers at 0400. Doc known as a real ********, demanding and unforgiving. Both babies had very similar names, realized the wrong baby on the circ board half way through the circ. Thank goodness other baby was going to be circ'd that morning anyway, just done by a different doctor. Big investigation and now a change in practice including new consents with area for MD to sign acknowledgement that they properly identified baby prior to circ.

[nedanurse]

Hey is this still a good thread. I have to say that it has been very helpfull to me. I am a new nurse 1 yr only so thanks for all the great advice and I hope I wont make a mistake but I know that some day it will happen. I hope that I get the same support in person as you have given eachother on this site

[flashpoint]

I once gave Mr. E. Smith his wife's meds...(she was Mrs. E. Smith). Poor Mr. Smith got Premarin! The doctor told me not to worry about it and Mr. Smith came out of his room for lunch wearing his wife's flowery hat and had socks under his shirt at chest level. He was always a prankster. :)

I've made others, but this is one I will never forget.