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.
I didn't know Vistaril wasn't supposed to be given IV until my charge nurse years ago gave it and the error was caught the next shift. No harm was done, the patient never even complained of any pain (amazing since this patient was a MAJOR complainer). But all of us nurses that worked with her learned from it.
I followed a nurse and noticed this nurse had not signed off any dayshift meds (sometimes we just forget to sign, that's not a major sin). I pointed this out and the nurse promptly signed them all off. When I saw the patient (very alert person) he was furious because he had not had any care all day including not getting any meds all day. What could have been taken care of by the nurse going in and giving those meds then became a major issue with that nurse getting fired for false documentation. I wouldn't have written this nurse up if she had given those meds late (they were all once/day meds).
I saw a very serious error (don't even feel comfortable describing it) that resulted in a good experienced nurse losing her job and the patient nearing dying. She was trying to work even though she knew she should have called in sick. I'll just say, Pyxis can be a wonderful tool but be very cautious!! I learned a lot from that situation, thankfully the patient wasn't permanently harmed. I couldn't believe she could make that mistake when she was the experienced nurse and I was a newbie, made me very very cautious about all meds.
Also. . .
There was a thread much like this one that was started about a year ago. It was initially almost stopped (not locked, the moderators were cool) because some of the nurses reading it thought it was inappropriate. This even though the OP's stated intent on that thread was also to learn from errors. I disagreed but respected the others feelings. I know how much I've learned from the errors of others.
I have given Vistaril IV more times than I can remember :uhoh21: (As have many of my co-worker). With a doctor's order, of course (not saying it makes it rright!!!). I've seen IV Push contraindicated
MD wrote order for "2 units PRBC's over 2-3 hours with 20 mg of Lasix in between." Should have read over 2-3 hours EACH. Guess who wound up wearing the goat horns on this one! [Hint: it wasn't the doctor!]
Pharmacy doubled concentration of dilaudid in PCA pump, but nurse did not change rate of pump, therefore pt. got twice the ordered dose. This was not caught for 2 days (3-4 different nurses involved). Patient very drowsy, but still in +++ pain with terminal cancer. Turned out she had a hematoma in a muscle, caused by the tumor. (Never heard of this before or since!) I think they drained it by needle. However, shortly after, patient had to go into hospice, as case getting too much to manage at home. (This one made us sweat bullets, as son was a lawyer!!)
I saw a very serious error (don't even feel comfortable describing it) that resulted in a good experienced nurse losing her job and the patient nearing dying. She was trying to work even though she knew she should have called in sick. I'll just say, Pyxis can be a wonderful tool but be very cautious!! I learned a lot from that situation, thankfully the patient wasn't permanently harmed. I couldn't believe she could make that mistake when she was the experienced nurse and I was a newbie, made me very very cautious about all meds.
When I was new I got talked into working OT even though I was exhausted. I mixed 2 lady's meds up in the same room my last med pass. I was horrified...no damage done, but it opened my eyes to how fallible nurses are when we are OVERWROUGHT, sick, exhausted, etc. Our job is tough enough when we are well even if we are very experienced...today's workload is so intense.
Knowing this is part of why I am not working as a nurse now...my health problems have caught up with me, the work environment is too stressful and I worry I will make a mistake.
When applying or removing Nitro patches, wear gloves.
I was working in a nursing home and was dispensing meds to 75 patients at HS. I took off a guy's patch and continued on. I worked with one cna on nights. In the earlier hours of the morning the cna came into the office to see me about something and found me asleep. She could barely keep me awake. All I could say was that I felt like I wanted to throw up. She took my BP. It was 60/30. All from removing a patch? Indeed. I went to my GP after work (hubby drove!). and explained that I fell asleep and work and was feeling gross. She asked about what I had been doing and I said that I had been at work. Nothing unusual there. She asked if I had taken off any patches. I said yes, of course, I do it every night. My BP was still in the basement, along with my HR at 44. She then explained that not only am I sensitive to nitro, I have a low normal BP and HR. there is enough nitro in a used patch to cause me some serious damage, even just pulling the edges to take one off. I was floored, literally. I now warn my students and coworkers. Washing your hands afterwards just disolves the glue faster, and gives you a higher dose. Not something I want to experience again, so I now wear gloves!!
As a student one of my classmates made not one but TWO MAJOR med errors, the first one the pharmacy sent the wrong med, the pt was supposed to get quinidine and they sent quidine (not sure of the spelling myself now lol) or vice versa anyway classmate gave the med even though to reach the dose she had to give EIGHT pills.
Then a few weeks later we were in LTC and she told us she was gonna do the noon med pass alone we questioned her about was she sure this was a good idea, we had only been at this facility for two days and regardless were NEVER to pass meds unsupervised but she did it anyway, and ended up switching two gentlemans meds, one had NO ill effects b/c he only got one or two meds and they were all fairly benign, the other however got phenabarb, ms contin, ativan, and several bp and cardiac drugs about 14 meds in all most of them at high doses, he went into a coma and died 6 months later without ever waking up. The licensed nurse who my classmate was working under got fired and disiplined by BON, and my classmate went on to get her license, from what I have heard her practice hasn't improved.
As a new grad I once gave the wrong med to the wrong pt I gave one dose of a predi-pak, thankfully the lady I gave it to was on routine prednisone like 40 mg a day if I remember right so she tolerated it fine but I will never forget that absolutely terrifying feeling. I wrote myself up, called the MD, and my DON was in tears by the time it was over, but I got ALOT more careful after that. Then had to call the pharmacy to deliver the missing dose of the predi-pak so that the correct pt could recieve her meds.
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.
Tiffy, the other thread seemed to call for opinions and conclusions. This one does not. In fact, I asked posters to please NOT identify particulars, but only what the error was.
The reason is that the new grads out there will now have a little more of a clue as to meds that are given the wrong way, and hopefully, they'll be prevented from an error.
I cannot imagine how anyone could have a problem with that. No one's forcing anyone to post. And even I have learned quite a bit from this thread.
When I worked in CCU a patient had a standby bag of D5W with Epiniephrine. It was labelled with a red sticker that Epi had been added. All patients in CCU not on IV had a lock, with a standby bag of plain D5W. All plain bags were also labeled with a red sticker and the date the bag was hung. (Only good for 24 hours) At any rate, my patient went into CHF and needed some lasix IV push. The nurse giving the lasix ASSUMED it was a dated bag of plain D5W, and used the bag to flush the IV lasix. She was not looking at the monitor, nor the patient. She was looking at the wide open drip rate that she intended to run for 30 seconds or so. I returned from lunch and saw the monitor showed an extemely rapid SVT. As I rushed over to the bedside it was apparrent the patient was unresponsive. I immediately recognized the cause, and shut off the flow. A code was called. The patient survived without ill-effects. This was a very horrible experience for all concerned. We stopped dating IV bags with red labels. I have never initiated a bedside IV bag since then without first reading the label.
Another nurse I know hung a bag of NS for irrigation as an IV of NS. The bag was clearly labelled by the manufacturer in red print on the bag instead of black print, and she said she wondered why it was red, but never bothered to check. There were no ill-effects to the patient.
A frequent med error made by the patient is to over use Timoptic drops. Timoptic (Isoptin) is the sam drug as verapamil and over use will cause heart block. I can't even begin to say how often I have seen patients needing temporary pacemakers to deal with this self administered drug error.
This is a good learning thread IMO. I'm sure it might be scaring our non nurse 'lurkers' to death wondering just how many booboos are happening out there...LOL! When one considers the thousands of meds one nurse may pass every week without an error then we're being realistic.
But when we start with the premise 'we are all human thus we WILL make mistakes', feel free to share those mistakes and look at the system vs simply blaming the nurse, we begin to problem solve, IMHO. :)
A frequent med error made by the patient is to over use Timoptic drops. Timoptic (Isoptin) is the sam drug as verapamil and over use will cause heart block. I can't even begin to say how often I have seen patients needing temporary pacemakers to deal with this self administered drug error.
Whoa!! Thanks so much for that one! I had no idea! I'll keep an eye out (no pun intended ) for that as we seem to get a lot of patients who've recently had cataract surgery and need frequent gtts.
Quote: "A frequent med error made by the patient is to over use Timoptic drops. Timoptic (Isoptin) is the sam drug as verapamil and over use will cause heart block. I can't even begin to say how often I have seen patients needing temporary pacemakers to deal with this self administered drug error. "
Timoptic (timolol) and Isoptin (verapamil) are NOT the same drug. Timolol is a beta-adrenergic receptor blocker and verapamil is a calcium channel blocker. Timoptic is the brand name of the topical ophthalmic preparation of timolol. Isoptin is one brand name of verapamil, an oral medication.
Right after I started in my current job (I have been here 5 years) I was going to flush a Saline Lock for an LPN-our facility has strange rules about IVs-I asked the LPN to draw up the Saline for me prior to my arrival on the unit. NEVER TRUST ANYONE WHEN YOU ARE TALKING DRUGS. I had started to flush the SL when, for some reason I asked her "This is Saline right?" She hesitated just long enough for me to realize 'Uh Oh, looks like trouble' She went and got the vial of "Saline" to show me-IT WAS POTASSIUM. I had fortunatley only pushed about 1/2 cc. No harm done that time. I cannot stress the importance of pulling it yourself if you are going to take the responsiblity of the outcome. I have never again asked someone to set something up for me. I know this was too dumb for words. It will not happen again. So I guess it was a lesson for me.
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) for that as we seem to get a lot of patients who've recently had cataract surgery and need frequent gtts.
TiffyRN, BSN, PhD
2,316 Posts
I didn't know Vistaril wasn't supposed to be given IV until my charge nurse years ago gave it and the error was caught the next shift. No harm was done, the patient never even complained of any pain (amazing since this patient was a MAJOR complainer). But all of us nurses that worked with her learned from it.
I followed a nurse and noticed this nurse had not signed off any dayshift meds (sometimes we just forget to sign, that's not a major sin). I pointed this out and the nurse promptly signed them all off. When I saw the patient (very alert person) he was furious because he had not had any care all day including not getting any meds all day. What could have been taken care of by the nurse going in and giving those meds then became a major issue with that nurse getting fired for false documentation. I wouldn't have written this nurse up if she had given those meds late (they were all once/day meds).
I saw a very serious error (don't even feel comfortable describing it) that resulted in a good experienced nurse losing her job and the patient nearing dying. She was trying to work even though she knew she should have called in sick. I'll just say, Pyxis can be a wonderful tool but be very cautious!! I learned a lot from that situation, thankfully the patient wasn't permanently harmed. I couldn't believe she could make that mistake when she was the experienced nurse and I was a newbie, made me very very cautious about all meds.
Also. . .
There was a thread much like this one that was started about a year ago. It was initially almost stopped (not locked, the moderators were cool) because some of the nurses reading it thought it was inappropriate. This even though the OP's stated intent on that thread was also to learn from errors. I disagreed but respected the others feelings. I know how much I've learned from the errors of others.
https://allnurses.com/forums/showthread.php?t=51736