Med Errors

Nurses Medications

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PMHNP10

1,041 Posts

Well, that was a dilly, wasn't it? I would love to have been a fly on the wall of that thought process.

I didn't make the 3rd check when putting the med back in the bin; it was stored in a little baggy adjacent to the diazepam; was the same size and shape, and both ended in azepam; I wrote myself up for that one :imbar

stevierae

1,085 Posts

My med book says never give it IV or SC and use the Z-track method of IM.

Our pharmacist will be here soon. I'll ask him.

It is an antianxiety/antihistamine/sedative-hypnotic, antiemetic . . . . I've given it with Demerol IM before.

hmmmmmm . . .

steph

Yeah, now that I think about it--when I worked ER, also in the 70's, we gave it IM, in combination with Demerol, for severe migraines. But, then again, we didn't routinely start IVs on migraine patients in those days, so we wouldn't have had IV access anyway.

But now I am troubled by the distant, albeit dim, memory of giving Demerol and Vistaril IV in Labor and Delivery in the '70s--

and if it is, indeed, contraindicated, as Angie said and your sources seem to validate--

then that means--

THAT MY FELLOW CORPSMEN (and the Navy RNs working with us) AND I MADE MED ERRORS!!!!! OMG!!!! :uhoh21:

Arrrgghhhhhhhhh!!!!! I guess this proves the point of the posters in our other recent discussion who insisted, "Everybody makes med errors. EVERYBODY. Even YOU!" (meaning me.)

Man, this really depresses me--even if it took place over 30 years ago. :crying2: I am going to go back to sleep and try not to dwell on it. I can only hope that, AT THAT TIME, that giving Vistaril IV was acceptable (we hadn't yet heard the phrase "standard of care.")

UM Review RN, ASN, RN

1 Article; 5,163 Posts

Specializes in Utilization Management.
I didn't make the 3rd check when putting the med back in the bin; it was stored in a little baggy adjacent to the diazepam; was the same size and shape, and both ended in azepam; I wrote myself up for that one

Thanks for the explanation. I can see how it happened now. And also, sorry, I didn't mean to embarrass you by my comment, I was genuinely trying to figure out how it happened.

You did the right thing by writing yourself up over it, but really, you needn't have told us that you made the error, just what it was and how it happened, ok?

We all appreciate your candor because it'll help us. :)

UM Review RN, ASN, RN

1 Article; 5,163 Posts

Specializes in Utilization Management.
I can only hope that, AT THAT TIME, that giving Vistaril IV was acceptable (we hadn't yet heard the phrase "standard of care.")

Stevierae, please don't beat yourself up over this, for several reasons:

It may not have happened the way you remember it.

I believe that giving Vistaril IV was something that was indeed a later development, else how could anyone have cited the neurological adverse effects?

Why were docs prescribing it that way if it NEVER had been given that way? I mean, that'd be like a doc prescribing (for example) IV Motrin, wouldn't it? You'd know immediately that it was wrong.

UM Review RN, ASN, RN

1 Article; 5,163 Posts

Specializes in Utilization Management.

Aha! After some Googling, I think I found the reasons Vistaril is not given IV.

From: http://www.wellcaremc.com/drugs/mg/hydroxyzine.htm

Do not administer parenteral solution SC, IV, or intra-arterially; tissue necrosis has occurred with SC and intra-arterial injection, hemolysis with IV injection.

So I thought it would cause a neuro problem, instead it appears that hemolysis would be the problem.

Anyhoo....carry on! I'm learning a lot here.

PMHNP10

1,041 Posts

Thanks for the explanation. I can see how it happened now. And also, sorry, I didn't mean to embarrass you by my comment, I was genuinely trying to figure out how it happened.

You did the right thing by writing yourself up over it, but really, you needn't have told us that you made the error, just what it was and how it happened, ok?

We all appreciate your candor because it'll help us. :)

No worries. I have no problem saying I screw up; but actually my error wasn't too horrible because the error I made was pretty equivalent to the actual med--three 0.5 mg tabs vs three 5 mg tabs-if anything I might have undermedicated him. This and my b&o supp definitely offer examples that you can't be too careful when preparing meds. Thankfully none of those errors were fatal.

boulergirl, CNA

428 Posts

Specializes in Home care, assisted living.

Noticed that two med techs signed out a resident's insulin, something we are not allowed to administer--only the home health nurse is allowed to do. We caught this error just before our facility went through an audit. :eek:

TracyB,RN, RN

646 Posts

Specializes in jack of all trades, master of none.

when i worked night shift, man we would find some doozies.... orders written by MD at 0800, never carried over to mar, pain meds, labs to be drawn, blood ordered but never given, wrong IV solutions hanging... the list could go on & on & on, but I just don't have the energy to be specific about it..... Except for the Procrit that was supposed to be given to a patient 3 x's wk, who didn't get it all for one week, then the following week, when I returned from vacay, I was the lucky one who got to call the doc for that one.... man was he pissed!!!!

I have written myself up on occasion for med errors, fortunately nothing major, but it really does humble you. My co-workers thought I was going way overboard for writing myself up, , but I would much rather discover my own error on my own & be the one to call the MD. People respect you so much more, when you say, hey, I screwed up & own up to it.

Tweety, BSN, RN

34,248 Posts

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.
Aha! After some Googling, I think I found the reasons Vistaril is not given IV.

From: http://www.wellcaremc.com/drugs/mg/hydroxyzine.htm

So I thought it would cause a neuro problem, instead it appears that hemolysis would be the problem.

Anyhoo....carry on! I'm learning a lot here.

There was a tale when I started this job 13 years ago about a nurse that caused cardiac problems in a patient that gave vistaril IV, so I always thought IV would cause cardiac arrythmias.

Tweety, BSN, RN

34,248 Posts

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

Oh, I forgot this one that I personally was involved in. I was the charge nurse and an LPN's patient was having rapid afib, so called the doc and got a dig order. I being the RN administered the dig. No response whatsoever. However, I noticed another patient's heart rate drop to the 50s after having been in the 80s.

You got it, the telemetry boxes were mislabled on the screen I was watching. (They aren't room assigned, we have to assign them and put their names on them.) Never did it dawn on me that this could have been a problem. Lesson learned.

Tweety, BSN, RN

34,248 Posts

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.
Found Vancomycin hung to gravity---Needs to be on a pump. If given too fast, it can cause Redman Syndrome.

Thank you. I had to look up Red man's syndrome. Didn't know that. So I learned something too. :)

UM Review RN, ASN, RN

1 Article; 5,163 Posts

Specializes in Utilization Management.
I always thought IV would cause cardiac arrythmias.
It can, Tweety. But apparently those are part of the normal possible s/e's, and not caused by IV administration.

From this website:

http://www.healthdigest.org/drugs/hydroxyzinehydrochloride.html

Side Effects: Low incidence at recommended dosages. Drowsiness, dryness of mouth, involuntary motor activity (rarely, tremors and convulsions), ECG abnormalities (e.g., alterations in T-waves), dizziness, urticaria, skin reactions, hypersensitivity. Worsening of porphyria. Marked discomfort, induration, and even gangrene at site of IM injection.
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