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.

[Spidey's mom, ADN, BSN, RN]

Well, our pharmacist says that Vistaril can be given IV . . same as Haldol, which should be given po or im . . we give it IV sometimes.

I guess there are reasons I remember giving it IV.

Gave Haldol IV this a.m. too. :)

Just got pulled off the floor to do an induction . . .

later.......steph

[stevierae]

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

Yeah, that's why Vanco needs to be given over one hour.

In the OR, we never put anything on pumps--if it is Vanco or Flagyl, or even a vasopressor, we either put a dial-a-flow on it or run it through minidrip tubing.

Now, anesthesiologists give everything IV push. Years ago, I had a student in my room, and I was teaching her about the Vanco we had just reconstituted to add to a 250 cc bag of IV fluid and prepare to give IVPB, about the need to infuse it over one hour, and about redman's syndrome (including the hypotension that is part of it) and this anesthesiologist, showing off to the student, told her that HE never saw that happen, that HE gave EVERYTHING IV push, yada yada yada, and proceeded to show her by doing just that-- grabbing the syringe with the reconstituted Vanco and giving it rapid IV push before we could stop him.

Patient, of course, turned brick red and went hypotensive. Fortunately, he was intubated, so airway was not a problem, and I think the anesthesiologist gave Epi or maybe Ephedrine to reverse the hypotension that he had caused. He was such a cocky guy, though, that he was not even a tad embarrassed by the situation he had created. He just carried on as if nothing unusual had taken place. I'll bet that that student had a great time telling that story at her post-conference that day!

[UM Review RN, ASN, RN]

Well, our pharmacist says that Vistaril can be given IV . . same as Haldol, which should be given po or im . . we give it IV sometimes.

Wow. This thread is getting very interesting, Stevielynn!

My drug book says not to give Vistaril IV. It's a Lippincott 1999 ed. (The new one's at work.) I don't have access to the Pharmacist until tonight, but if I get a chance, I'll ask her, because now I'm really curious.

So stay tuned for more on The Vistaril Solution...

(OK, not a great pun, but hey, I tried....) :chuckle

Haldol, on the other hand, can be given IV, according to the drug book--apparently there are two forms of the drug, haloperidol lactate and haloperidol decanoate. Haloperidol lactate, it seems, is the IV form of haldol that has "unlabelled use" as an IV med "in acute situations."

There's also a section in "Nursing Considerations" that states "Do not use haloperidol decanoate for IV injections."

I'm not very familiar with Haldol IV, as we can't give IV Haldol on our Progressive Care unit. Hospital policy states Haldol can only be given IV in ICU areas; the rest of us can only give it IM. (Perhaps we only have the deconoate form in our Pyxis?)

[veteranRN]

I had a physician increase my Tenormin from 25 mg to 100mg. This for a 37y/o female with recently diagnosed high blood pressure. Luckily, I realized this was the cause of my crushing chest pain and a pulse of 37.

[allele, LPN]

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! :)

[Spidey's mom, ADN, BSN, RN]

Angie . . .pharmacist says Vistaril is supposed to be only given IM but as in all things there are exceptions . . . :chuckle

steph

[UM Review RN, ASN, RN]

Angie . . .pharmacist says Vistaril is supposed to be only given IM but as in all things there are exceptions . .

Ahhhh....I get it. You were testing me, weren't you?:chuckle

[weetziebat]

I've seen a 16 year old boy, who was in for an appendectomy, die because he was given pre-op meds on the floor, nurse forgot to document, and was given additional pre-op meds in O.R.

Demerol 100 mg. given fast I.V. push - the patients heart did really funny (not Ha Ha) things for about an hour afterwards. Dr. was never notified, nor was it charted.

Cup full of meds given to wrong patient. CMA denied it and no follow up.

P.O. meds crushed fine and given I.V. by someone who "didn't realize" it wasn't done that way.

Fictional blood sugars written cause nurse "didn't have time" to do them. This was on patients who normally had normal results.

Patients overmedicated with sleeping meds. For example med to be given Q 4 hrs. prn but given after 2 hours cause patient not sleeping, then was charted as being given Q4.

RN in ICU gave patients NS instead of Demerol cause she was injecting herself. This went on for months before it she was caught. Patients, in the meantime, suffering without relief.

This happened to me. Went to see specialist for sciatic nerve pain. Sitting next to doc with my chart clearly labeled, in red, that I am allergic to Sulfa. He gave me samples of Celebrex. I looked it up in the drug handbook and no mention made of it being related to sulfa - (Notified them and got reply that they had added it to more recent additions of drug book).I had a very nasty rash over my entire body. PCP diagnosed it. Said he'd learned the hard way too, as he'd given it to another patient also allergic to sulfa. I called the specialist to let him know. He refused to speak to me, and later found out he was in the process of moving out of the country because he was tired of patients getting big bucks in lawsuits against MD's. Hmmm......................

[RN4NICU, LPN, LVN]

P.O. meds crushed fine and given I.V. by someone who "didn't realize" it wasn't done that way.

WHAT???!!!

:eek:

S C A R Y ! ! ! !

[Spidey's mom, ADN, BSN, RN]

Ahhhh....I get it. You were testing me, weren't you?:chuckle

No no, just clarifying . . . I was a bit disjointed today starting out a floor nurse and ending up doing a pit induction . . . had to change hats midstream and this was when I got on the computer for a sec to post my convo with the pharmacist.

I would never test you. You are too smart for me. :)

steph

[11:11]

comitted by a nurse working under contract from another country...

...was late with her meds (first mistake)...

.. so hung two IVPB abx at the same time, one to a norcuron drip and one to a versed drip and set pumps for 200cc/Hour (second,third, and fourth mistake)...

...Forgot to unclamp said abx's (fifth mistake)...

I'll let you guess out how long the code lasted and the outcome of the pt-

[Shed13911]

Had a new nurse in the newborn nursery give a baby boy 9cc of Infant Tyl concentrate, after he being circumcised, AND then ask the charge nurse why they made the Tyl bottle so tiny with little more than one dose in it. The baby ended up OK but had to have dialysis. Parents were shell shocked as they were getting ready to go home that day.

Had another nurse give a near comatose patient her Metamucil with only a small amt of water. It was a tragic thing for me to walk in and find her with her airway occluded and it too late to save her. That happened more than 25 years ago but I never forgot!

I had a supervisor that hung the wrong IV fluid on a crashing OB. She found the mistake after the crisis. She said that she pulled it out of the right slot but it had been put in the wrong bin. She blamed everyone but herself since she never glanced at the bag while she was running back to the patient.

Had another RN give 10 times an oral MSO4(morphine) to a critical care infant and not realize it until he stopped breathing!! He made it through the event but the cocky RN who thought she NEVER made mistakes found out that she was human too that day!!!!!!!

I really can't remember the rest right now but I have learned alot from the thread! Thanks for all of the honesty guys. No one practicing nursing/medicine can say that they do not make mistakes!!