Med Errors

Nurses Medications

Published

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.

We just had a staff meeting yesterday were it was stated we can no longer take an order that reads "xxxx prn med given 4-6 hours" we must have an exact time q4 and the Doc must state if the med is for pain or whatever. We also can't have an order that says 1-2 tabs, it must state exactly how many tabs.This should be fun getting the Doc to nail down an exact time for PRN meds.
Doesn't nailing down exact times and amounts defeat the purpose of an AS NEEDED order?? You give what the patient needs at the time, it is called nursing discretion. I know, I know, I have heard all the mumbo jumbo that the q 4-6 hrs and 1-2 tabs puts nurses in the position of "prescribing" medication and going beyond scope, but that is just bull****. We are knowledgeable about the medications and our patients status. There is no logical reason that a licensed nurse should not be able to use discretion with orders given as parameters, rather than spelled out to the exact minute and dosage. Just curious, if their Fruit of the Looms are in a wad over the PRN meds, how do they feel about nurses titrating drips?

I had a very nice pt COPD, Emphysema and is a known CO2 retainer and was very sensitive to O2.. Came in very acidotic but was managed well after almost a week.. Finally, its a happy day the following day for he is due for home, as endorsed to us nyt staffs. While having the handover, a staff from next door bid goodbye and uttered ive done one good job off you guys. He decided to help out the pm staff by giving the nebs in our respi ward.. Anyway, time to do our rounds and by the tym we reached the said pt, he is already unresponsive, breathless and all blue.. To find out, his nebs were delivered O2 driven, w/c is given at 5L per hospital policy - but not to COPDs or CO2 retainers!!..

Twas a sad night for us, for it was too late for him.. Sigh! A staff volunteered to give nebs to pts of which he is not familiar w/. But then we have color codes for lists of pts who must use a compressor and those for O2 driven. So we dunno if he ignored it or what..

From then on, the staffs have been very careful in identifying a CO2 retainer/O2 sensitive.. COPD, Asthmatics, Bronchitis, Bronchiectasis, Emphysema, etc. - once they get better, are shifted back to their usual inhalers...

Specializes in SICU-MICU,Radiology,ER.
... if their Fruit of the Looms are in a wad over the PRN meds, how do they feel about nurses titrating drips?
I agree whole heartedly. I suppose Im thankful for joint commision and all the other commisions etc out there that research nursing and try to make our care safer.

But sometimes I think its getting a little out of hand not to mention hypocritical. While ancillary disciplines do more and more, nursing gets more restrictive?

I think the solution is further and continuing education and I dont mean outside the hospital but inside and on a regular basis.

One small hospital I worked at had quarterly inservice with nursing and pharm together, mandatory with relief provied so all could attend. This would be difficult in a bigger facility but it could be managed.

If its true 40,000-95,000 die a year d/t med errors you'd think it would be a worth while investment-

11

"how many times have wrong medications been administered because there was no process in the pharmacy to assure that the correct meds were being put into the cart cassette?"

no excuse--remember the 5 rights of medication administration? remember reading the label before dispensing the medication? to me, this excuse would never fly in a court of law--while the person who stocked the cassette (phamacy tech or whomever) the nurse is still responsible for her own actions, according to the ana code of ethics for nurses with interpretive statements, and needs to be held accountable.

"how many physicians' crappy handwriting have resulted in wrong meds/doses/etc. -- and how many pharmacists and nurses have been blamed for not being able to read completely illegible orders?"

again, no excuse--if you can't read an order, then you call the person who wrote the order and clarify it with him--you don't simply guess and hope for the best!!! again, you are held accountable for your own actions, and need to practice critical thinking to avoid errors!

"how many medication administration processes are so convoluted on paper and in reality that one needs an atlas and a mining helmet to make her way through it then ends up free-wheeling it because there's no clear expectation of the steps in the process?"

what? i do not understand this statement, at all. please elaborate--please give an example of "a med administration process that is convoluted on paper and in reality." no excuse for "free wheeling" if you find yourself lost--you simply don't give the med until you are clear on what you are doing!!

obviously, individuals who look for ways to avoid being held accountable for errors--often careless and thoroughly preventable errors--that they committed are a soapbox issue with me.

i do agree that "systems error" can occur, and i certainly agree that root cause analysis of any sentinel event needs to take place. i absloutely agree that anything--anything--that can possibly make patient care safer should be done. i also believe, however, that even in the event of "systems error" as part of the investigation process the individual still needs to be held accountable for the part he or she played in committing the error. the fact that 2 or more vials are known to have similar labeling, shape or color is even more reason to be extra careful in reading the label before dispensing--not citing "systems error" as one's defense and hoping to deflect your own responsibility in the matter.

I went five whole years as an RN before I made my first real med error...and it was a doozy (it's been 2 yrs & I'm still dealing with the state board). Thankfully, the pt suffered no lasting ill effects & recovered quite nicely, but this taught me a very valuable lesson; check, check, & recheck again to ensure you are following the 5 rights. I have passed this lesson on to my students (I'm a clinical instructor for 2nd yr ADN students as well as an ED nurse) by ensuring that after checking the MAR & the meds, they ask each pt each time they walk into a room what the pt's namae & DOB are while checking the name band...even if they were just in that room 5 mins before. Can never be too careful.

I myself was a patient at a large urban hospital. I was 5 weeks pregnant with hyper-emesis, a ruptured ovarian cyst and I was also very hypotensive (80/30 lying) and I was febrile. I was admitted to med/surg floor. I was on IVF running at 125cc/hr and had a prn order for Phenergan IV. When I requested the Phenergan the nurse's (always a different nurse) would hook the syringe up to the pump and turn the rate down to 50cc/hr and run it in. The last time I requested the Phenergan I didn't notice until it was too late that the nurse left the rate at 125cc. I also found out later that the other nurse's gave me 12.5mg of Phenergan and this last time the nurse gave me 25mg. At the time I was on the phone with the insurance co. letting them know I was admitted when I felt horrendous burning at the IV site and up my vein. Then I couldn't see, speak or hold my head up. Luckily as soon as I felt the burning I knew what was wrong and pressed my call light. Luckily because immediately after I was completely incapacitated!!! When the nurse came back she said "Oh I guess I forgot to turn down the rate." She didn't even act like she did anything wrong or had any concern. She then turned it down and turned around and left. When I could see and was able to lift my head up I turned back on my call light. She came back in and I told her she was going to have to change my IV site because my vein was ruined!!!!! The IV site was changed but not by her. I didn't ask for anymore Phenergan and got out of there ASAP!!!!! I was literally afraid I would die if I stayed much longer.

During this same hospitalization I was in a with an elderly woman. She put her call light on at about 12am and asked for Tylenol for a headache. The person who answered the light said "Ok I will go tell your nurse." No one came...then she put the call light on again around 2:30am and a different person came in. She again asked for Tylenol for a headache. This person said "Ok I will go tell your nurse.". No one came... then she put the call light on again around 4am. A different person came in the room and she again asked for Tylenol for a headache. That person said the exact same thing "Ok I will go tell your nurse" and still no one came!!!!! Her doctor came into the room early at around 5:30am to tell her she had cancer and that she had to stay in the hospital so they could do surgery ASAP. She told the doctor that she had been asking for Tylenol all night for a horrible headache and no one has been in to give her any. Finally about 1/2 hour after the doctor left a nurse came in to give her Tylenol. No apology or anything! Neither her or I slept all night!!

As a nurse I just could not believe that happened. It just looked so bad. If I hadn't been so sick I would have gotten up and found someone, but as it was I was so sick I couldn't even take care of myself.

And there is more... when I was admitted from the ER to the med/surg floor I was brought up and moved from the ER stretcher to the floor bed. The guy who brought me up left me there saying "I will go let them know you are here." That was at about 1am. No one came and no one came and as I said before I was so sick I just laid there. A few times I saw someone walk by but they didn't come in. Then at about 4:30am I saw someone walking by and look in. The person said "Oh my Gosh, how long have you been here. We didn't know anyone was in this bed." I told them I had been here since about 1am and they were shocked. I had been there for 3 1/2 hours with an IV running and very sick!! When a person is that sick you can not take care of your self!! It is vital that things like an admit to the floor is communicated!!!! I know how busy and hectic things can get and I am sure I am more understanding then I should be sometimes, but I had held this hospital in very high regards before this hospitalization. Now I would definately go somewhere else if I were ill.

And I really am not making this up!! There were a couple other things that happened during this stay but this is already too long of a post so I will end on that note.

I was in the OR when one of our surgeon's got a frantic call from a nurse in the ICU - somehow, a nurse had given the patient 30cc of Maalox IV. (Yes, you read it right - IV.) The surgeon looked at me and, surprisingly calmly, said "She just killed him". He was right - the patient coded while we were still on the phone with the ICU nurse, and didn't survive.

Specializes in Rehab, Step-down,Tele,Hospice.

Jwk, sorry but I just dont get your post. It doesnt even make sense that a nurse would do this! Im shaking my head in wonderment.

Scary Scary Scary.. ok please tell me how you can even physically do this? I realize that Im a brand new nurse but I just dont "get it". :uhoh3:

Jwk, sorry but I just dont get your post. It doesnt even make sense that a nurse would do this! Im shaking my head in wonderment.

Scary Scary Scary.. ok please tell me how you can even physically do this? I realize that Im a brand new nurse but I just dont "get it". :uhoh3:

Trust me, we were shocked/amazed this happened as well. More surprising is that it happened with an experienced RN. He/she just totally brain-farted. And this was before propofol was released, so it wasn't a matter of confusing the "white medicine".

The longer you're in medicine, the more amazing screw-ups you will see. A feeding tube in the lungs instead of the stomach, hooked to a pump, the patient died after their lungs filled up with a "feeding supplement". Anesthetic-related deaths are down dramatically since the advent of pulse oximetry, but there are quite a few deaths every year around the country from unrecognized esophageal intubations.

It ain't right, but as they say, S**T happens!

Howbout a demented pt who drank a hibiscrub in a medcation cup left by an EN ? Was only discovered when the EN get back ther and the med tot ws empty..asked the pt and admitted she drank it, thot twas Procodin... (teeeheee!!)

Tsk! Tsk! ****elnski shaking her head***

stevierae, I was simply pointing out that there are many variables involved in most errors. I agree that individuals should be held accountable.

Vistaril is extremely VESICANT to the vein, way worse than Phenergan. someone could lose an extremity!:)

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