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.
125 mg of Diltiazem infused in 20 minutes --normally infuses over about 12 hours--when that line was confused with the NS Bolus she was supposed to be getting.
The oncoming nurse found the error, and correction was immediately started. Pt survived.
125 mg of Diltiazem infused in 20 minutes --normally infuses over about 12 hours--when that line was confused with the NS Bolus she was supposed to be getting.
The oncoming nurse found the error, and correction was immediately started. Pt survived.
We have protocols in place now because of this sort of error, when certain drugs are being infused they cannot be piggybacked they have to be stand alone medications. Nothing and I repeat nothing can run with them
As time goes by, I'm happy to see safer practices put in place. Many med errors are partly due to bad systems, and most of the errors I've seen were of this type. This isn't to say the nurse isn't responsible, but if the system is set up poorly, it is more difficult to avoid errors. The more we can do to identify and correct bad systems, the safer the patient will be. This is why we no longer have bins of pure potassium in the med room.
At my old hospital, before we got a Pyxis, our stock meds were on labelled shelves. We used heparinized saline in our pressure bags for art lines and CVP lines; these were on the shelf right next to the Hespan. The bags were the same size, both had red lettering, and you really had to look closely to be sure you grabbed the right one. I asked the pharmacist if these two items could be placed in different areas to avoid mistakes; he said, "no, because they have to be in alphabetical order." Needless to say, putting hespan in a flush bag, or even worse, giving heparinized saline instead of Hespan was not an uncommon mistake.
My scariest near-miss EVER was when I had a LOL whose bp was in the toilet. I got an order for dopamine. I took the glass bottle of dopamine off the shelf and read the label. Our pharmacy (god knows why) had a policy of putting a big label over the bottle, secured with a rubber band. The label said dopamine. So I took it to her room, spiked it, primed it, set the pump, and rechecked the label again. Yep, dopamine. I don't know why I did it, but I looked under the rubber-banded label to look at the bottle itself, and it was NITROGLYCERIN.
I was shaking in my sneakers. I had not started the drip, thank god. I could just imagine starting the drip and seeing the patient's bp go lower- and what would I have done? Cranked up the "dopamine" of course, and cranked it up to the max. That LOL would have died right there. I went back in the med room and every single bottle of "dopamine" was really nitro. I looked in the other med room (we had two on our unit) and every dopamine there was really nitro, too. I called the pharmacist, he came up to the unit, and when he saw it for himself, he just about fainted. (Incidentally, every single one of those bottles was initialled by two people to verify that it was dopamine in the bottle.)
I saw another dopamine related near-fatal error, fortunately not my own. Although the floor stock dopamine was in glass bottles, if a patient had dopamine regularly ordered, the pharmacy would send it up in a 250cc bag. This bag had an orange label on it identical to the orange label used for Vancomycin, which also came in a 250cc bag.
So a nurse grabbed what she thought was vanco and ran it in over an hour, but it was dopamine. That patient crashed so hard... it was awful.
In nursing school, I gave a presentation on med errors and how to avoid them. One student in my class disliked me intensely, and she told me that I was "always so negative!" in response to my med error lecture. Well, she ended up working in the same ICU as me, and she put 100mg of Dilantin in a radial arterial line, thinking it was the CVP. The patient's arm turned necrotic and almost had to be amputated. She had several surgeries on the arm and it was saved, but totally useless. Too bad that chick didn't listen to my lecture.
Since then, I always instruct new nurses to clearly label "ART LINE" and "CVP" (and every other line, for that matter) on the tubing, because when your patient has a whole mess of lines going everywhere, you don't want to mistake one for the other.
I've been away from critical care nursing so I may have the dosages wrong. A patient was having a few runs of V-tach. A co-worker gave a 2 gram bolus of lidocaine IVP, instead of the 100 mg IVP dose. The patient was an alcoholic, it didn't phase him, he was fine!!!! Alcoholics can survive anything!
I've been away from critical care nursing so I may have the dosages wrong. A patient was having a few runs of V-tach. A co-worker gave a 2 gram bolus of lidocaine IVP, instead of the 100 mg IVP dose. The patient was an alcoholic, it didn't phase him, he was fine!!!! Alcoholics can survive anything!
except alcoholism; it often gets them one way or another
Specializes in Cardiac, stroke, telemetry,Med-surgical.
0700 A postop elderly has low blood pressure. 1L of LR, bolus at rate 250cc/hr was ordered by physician. Pt has peripheral IV with D5NS with 20mEQ KCL at rate 80cc/hr; 350 cc still left in the bag. Willing to help a day shift nurse (and simply being stupid) I hugged LR bag as a piggybag, changed the rate, but didn't connect the tubing. The pt got 350cc of D5NS with 20mEq KCl in 1.5hr. I was lucky that it was only 350cc; nothing happened with the pt or her vein or her potassium level (her potassium level was initially low)
Lesson 1. Never rush yourself. Check connections on pump.
Lesson 2. Don't be stupid. The easiest and fast way was simply to exchange bags and change volume and rate on the pump.
Specializes in Peds/outpatient FP,derm,allergy/private duty.
A nurse in our Definitive Observation Unit gave a 6 week old infant 0.10 ml of epinephrine instead of 0.01 ml. Thank God the baby was OK due to the rapid metabolism of epinephrine. My friend was terrified but she did not lose her composure throughout the incident and we all learned the principle that often a miniscule amount of a drug really is the proper dose, and errors of this type may occur more frequently to new grads in a specialty like peds right out of school because we are so much more familiar with adult doses in nursing school.
lady partsl suppository (premarin) given per rectum because the nurse didn't bother to ask the patient to bend her knees and open her legs. Administered it blind with the patient lying in bed with legs closed. When the applicator came out covered in feces, the nurse told the CNA that it looked like the patient needed her brief changed (brief [adult diaper] had just been changed immediately prior to suppository insertion).
CNA began to change brief and found medication seeping out of rectum. CNA made nurse aware. Nurse administered another dose correctly, and didn't document the error.
Specializes in Ward Nurse and everything in between.
Med error so far was the AP ordered a Dulcolax tab but I inserted suppositories. 2 even! That was a telephone order. I echoed it but somehow I didn't know why I made it such.
I'm a new grad and this thread is quite terrifying to me. I have never made a med error but I know of several nurses who have, fortunately they were not life threatening. Throughout nursing school in clinicals most facilities had a pyxis, however on occasion the wrong med would be in the wrong bin.
Needless to say, putting hespan in a flush bag, or even worse, giving heparinized saline instead of Hespan was not an uncommon mistake.
UM Review RN, ASN, RN
1 Article; 5,163 Posts
125 mg of Diltiazem infused in 20 minutes --normally infuses over about 12 hours--when that line was confused with the NS Bolus she was supposed to be getting.
The oncoming nurse found the error, and correction was immediately started. Pt survived.