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.
while pouring meds for a patient from ward stock of digoxin, when I poured several of the pills into the cap of the bottle, there were at least three different sizes and colours of pills to choose from!! - someone must have "replaced" some other pills into the container by mistake.
while pouring meds for a patient from ward stock of digoxin, when I poured several of the pills into the cap of the bottle, there were at least three different sizes and colours of pills to choose from!! - someone must have "replaced" some other pills into the container by mistake.
For some reason that made me laugh, hmm, today Mr. Jones you get a red pill two blue ones and a green one. Wish I could have seen your face when you discovered THAT one.
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.
I've always been afraid of that happening... especially with potasium and NS looking so similar. I'm glad you double checked and I agree.....Never ever push any meds or give any meds unless you prepared them yourself.
After so many years in nursing I feel this way about med errors. Many of them occur only because the nurse is overworked, stressed and rushed...trying to do more than one person can do in the time she has. When another nurse lectures and says 'there's no excuse' I wonder if we work in the same environment. It seems today there is so little support for us on the job, and we are not getting what we need to be successful in the workplace. Like we are being set up to fail so we can be scapegoats.
I feel more and more like the workplace itself today is just a 'mistake waiting to happen', with the workload, short staffing practices, the endless tasks and paperwork, the endless demands. No wonder there is a 'shortage' and so many nurses will not work as nurses any longer.
Thank you...I was wondering how to respond to "there's no excuse" in a productive way. You did so in a manner much nicer than I would have.
That said, here's my most ridiculous error (one for which I feel there really was no excuse): received a patient from the e.r. with three pages of orders. On the first page there was a list of drug allergies including fluoroquinolones (written that way...fluoroquinolones). Right below the list of allergies was a list of med orders including levaquin xxx ivpb qxx hours.
Well, the order went to pharmacy, where they entered the allergies and the drug and then sent me the drug. Normally I verbally verify allergies with patients but this lady was intubated and sedated. I proceded to hang it -- as i'm programming the rate into the pump and hit start it hits me...duh. The infusion is stopped and I write myself up (along with the physician and the pharmacist). I don't believe the patient received even 1 cc of the bag, but still...very scary. I notified both pharmacy and the physician (3rd year IM resident) of the error--the pharmacist was mortified, apologetic and confused (some system safe guard should have clued him in) and the physician was grateful and shaken. Thankfully, a good outcome and a good learning experience for all concerned.
OB... new nurse on orientation, started pitocin drip to gravity. Her preceptor told her to start the pit low, so she did, just not on a pump. Of course, the patient ended up in the section room for fetal distress.
Then again--when I worked OB, in the Navy, in the '70s before pumps were readily available (we did not have fetal monitors of any sort yet, either--we listened wuith the old-fashined, hand held fetoscopes, or, it FHTs were REALLY hard to hear, a doppler) we just slowed the rate way down, and, if we had one available, used a dial-a flow- or even just minidrip tubing to deliver IV Pitocin. I don't ever remember an emergency C-section for a ruptured uterus, which can result from too rapid IV Pit--but, perhaps we were just lucky, or God or some guardian angels was/were looking out for us.
I can remember various OBs saying, nonchlalantly, "Keep an eye on her...her uterus could rupture..." it was like those guys had encountered anything and EVERYTHING in their day, and literally nothing fazed them...they gave their own spinals, and we did tons--TONS--of mid and high forceps deliveries, without sequelae..
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
For me, this thread reinforced the need for med errors to be addressed with a multi-disiplinary approach, involving physicians, pharmacists, nurses, patients, as well as pharmaceutical companies/labeling practices. We nurses are the last line of defense, it is true; but we need to move from the environment of "blame games" to true multi-disciplinary problem-solving. Simple as that.
For me, this thread reinforced the need for med errors to be addressed with a multi-disiplinary approach, involving physicians, pharmacists, nurses, patients, as well as pharmaceutical companies/labeling practices. We nurses are the last line of defense, it is true; but we need to move from the environment of "blame games" to true multi-disciplinary problem-solving. Simple as that.
for me, this thread reinforced the need for med errors to be addressed with a multi-disiplinary approach, involving physicians, pharmacists, nurses, patients, as well as pharmaceutical companies/labeling practices. we nurses are the last line of defense, it is true; but we need to move from the environment of "blame games" to true multi-disciplinary problem-solving. simple as that.
this is precisely why i do not hesitate to 'write up' an occurence when it seems that it is more than a typical 'med ommission'. recently, there have been many chemo orders that were subject to interpretation. my theory is, if they see enough occurences surrounding chemo orders, maybe the orders will be written properly :angryfire
Thanks for your response, Tweety, that's exactly why I posted this thread. I'm always learning things from this board.
Anyhow, to respond:
Sorry, I should've specified--this was a KCL bolus of 20 mEq's in 100 ml's of NS. My bad. Our policies are the same.
The nurse in this instance (for whatever reasons I don't know offhand) questioned the dosage frequency to the Pharmacist, who recommended questioning the order. The order was changed. The patient was moved to another unit, where the order was changed again, back to the original. The med was given per order--and the patient subsequently went into convulsions, possibly from the metabolites in Demerol. (Is it possible that this Pt. had cirrhosis or something else that would cause an intolerance to the metabolites?)
At any rate, I now get very nervous when I see high, frequent doses of Demerol prescribed... :uhoh21:
I have not heard of problems with metabolites from demerol in the general population, but it is definitely a potential problem in sickle cell patient. On my pediatric unit, we never use it - always give dilaudid or morphine
The only thing that really comes to mind is a critical care nurse giving Lomotil IV to a patient. Not orally, but IV. Makes you wonder what she thought about how thick it was, and how she got it to go through the line. Patient ended up okay.
Student nurse gave PEG meds into CVC. Pt died. Nursing instructor (who was supposed to be supervising) was off the unit and the hospital blamed the primary nurse and fired him. He was a friend of mine. Nothing happened to the student who failed to obtain required supervision.
This is unbelievably SCARY and TRAGIC!!! I myself am a nursing student in my first semester of clinicals. That said, I must ask: what are PEG meds and what is CVC?
GingerSue
1,842 Posts
while pouring meds for a patient from ward stock of digoxin, when I poured several of the pills into the cap of the bottle, there were at least three different sizes and colours of pills to choose from!! - someone must have "replaced" some other pills into the container by mistake.