Med Errors

Years ago, I worked with a new graduate Practical Nurse who gave a patient two vials of Dilaudid 'IM'. The order called for Dilaudid gr.1/64 'IM' PRN, and the vials were labeled 1 cc = gr.1/32. Instead of giving one-half of a vial (0.5 cc), she got mixed up and gave 2 cc. Her patient coded, but survived, thank God. I can't say the same for her nurse, who was immediately demoted to an Aide and was never allowed to practice again. It was so scary, and I felt terrible for her. It could have happened to me...or any of us.

Most medication errors I come across are patients taking/mixing medications wrong. Taking their old coumadin with their new plavix, taking 325 asa instead of 81, taking 50 lopressor instead of 1/2 of the tab, which sets them up anyways for a med error. When ever they get their medications from the VA they are almost always white round pills, larger strength that needs cut and poor medication labels that I can hardly read let alone a elderly patient.

A nurse at our facility gave an infant an injection of Oxytocin instead of Vitamin K...

Hiya,

I'm confused, so I figure I'll ask! We don't work in CCs, so I don't understand them, but if I seen that the order was for 1/64 IM PRN and the vial said 1/32, I'd think that to get to 1/64 it would mean two vials. Now don't judge me, I know nothing of US medications, but I'd think if it said 1cc = 1/32, that could be correct, where have I missed something? (ps, i don't even know what dialudid is, lol, darned UK). Or, did you forget to say how many CCs there were in a vial?

Years ago, I worked with a new graduate Practical Nurse who gave a patient two vials of Dilaudid 'IM'. The order called for Dilaudid gr.1/64 'IM' PRN, and the vials were labeled 1 cc = gr.1/32. Instead of giving one-half of a vial (0.5 cc), she got mixed up and gave 2 cc. Her patient coded, but survived, thank God. I can't say the same for her nurse, who was immediately demoted to an Aide and was never allowed to practice again. It was so scary, and I felt terrible for her. It could have happened to me...or any of us.

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."

Angie and everyone else...FYI

Anything "Decanoate" is a long acting medication with an oil base used in psychiatric settings. It is given IM Z-trac with a 2 inch needle. I shudder to think what would happen if it were given IV.

Hiya,

I'm confused, so I figure I'll ask! We don't work in CCs, so I don't understand them, but if I seen that the order was for 1/64 IM PRN and the vial said 1/32, I'd think that to get to 1/64 it would mean two vials. Now don't judge me, I know nothing of US medications, but I'd think if it said 1cc = 1/32, that could be correct, where have I missed something? (ps, i don't even know what dialudid is, lol, darned UK). Or, did you forget to say how many CCs there were in a vial?

That's why you have to do the math and check with someone else. Intuitively, it seems like 1/32 + 1/32 = 1/64, but that's mathematically incorrect, because when you ADD denominators, the denominators stay the same. You'd actually have 2/32 or, simplified, 1/16.

I hope that helps.

PS Thanks for the information, Jacqui!

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?)

Can *any* deconate be given IV? Don't they ALL have to be given deep IM?

After a fire (I have asthma) Solu-Medrol 500mg q12h IV push ordered. 500mg given in ED, 2 hours later in ICU another 500mg IV push given. Oye.

MD ordered 200mcg Synthroid IV qd, RPh entered the drug correctly. Pharm Tech filled it with 200mcg tablet vs. vial. RPh missed it when he checked it. RN crushed tab, gave it IV. Pt okay.

Most amazing med error in my career... resident orders Augmentin 500mg. ICU nurse goes to give it PO. Resident argues and insists IV admin. RN (me) disagrees, Augmentin doesn't COME IV. Resident insults RN, RN insists PO, resident insists IV. RN gets PharmD, PharmD and RN walk into room as resident just finished pushing Augmentin IV. PharmD asks since when are IV meds pink and bubble gum flavored. Indian resident turns amazingly white. Pt okay.

Giving wrong pt antipsychotics (pt sedated but fine), adult dose of Dig given to NICU baby (baby died), hanging wrong IV solution (no problems), then...

We also have pt mistakes. Pt given Rx for AVC vag supps, came back 10 days later with no results, wanted new Rx because they tasted so bad, men using any supp c/o pain with supp insertion. They didn't know to remove the aluminum foil wrapper first. My favorite.. pt called c/o that she couldn't finish a bowel prep for lower GI. Reason... she didn't like the flavor of the enema tip. (that would be KY jelly) Now com'on people, since when does the medical profession give adults a baby bottle of salty solution with a long hard nipple and KY on the tip???

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.

The nurse is very correct. My 10# Shih Tzu has Glaucoma, has had since she was 4 months old. We have learned the horrors of Timoptic. She's been in doggy ICU from chewing up a bottle of Timpotic 0.25%. I also had to give her extra doses for increase eye pressure. I actually listen to her heart with my steth with I have to do this. Amazing what EYE drops can do to the heart.

Ok, this one was my bad. At the LTC facility where I worked we got the pre-printed MAR's around the 24th of the month or so, and they had to be edited by the last day of the month. On the unit where I worked they were never finished on time, leaving the 11p-7a nurse who worked on changeover night to finish whatever editing wasn't done before they could start changeover. Mind you, we couldn't even flag 12am meds until we changed over the MAR's for 45 residents. One night I showed up and there were still about ten residents MAR's that hadn't even been looked at. I checked them against the old ones as quickly as I could. 6 wks later a resident went to the hospital for a psych issue and we were contacted by DPH. That resident was on sulfaSALazine daily for colitis had been switched accidently to sulfaDIazine (an Abx) and was on the wrong med for 6 weeks. The pharmacy had misprinted the new MAR and I hadn't caught it. Then they sent the wrong drug, and I noticed the change (pill looked different) but since it matched the current (wrong) MAR, didn't investigate furthur. Fortunately she wasn't hurt. When the DPH investigator interviewed me I was very honest. I said "The first error was with the pharmacy, the 2nd was mine". They changed the way editing was done after that, actually followed the existing protocol that required 2 nurses to check each MAR.

Working at a jail I had a complete brain fart and gave PCN ordered after a dental extraction to someone whose chart clearly said "allergic to PCN". Fortunately the inmate turned out to not really be allergic. I had to sit with him all night holding an epi pen though just in case.

This one happened to me. It's kinda funny.... I had thrush from not swishing enough after using my Flovent. Called my PCP (who was a bit of a doofus) and asked for Mycelex oral lozenges to be called in. When I picked them up they were the lady partsl troches (I noticed before I put it in my mouth, thank god). When I got home I called the office and said to the nurse "um... he got the med right but he called it in for the wrong orifice" She stifled a giggle and politely asked, "He's here, can I put you on speaker phone?" Since I too was highly amused I consented and then repeated myself, apparently to the MD and ALL the office nurses. They were all still laughing pretty hard when we got off the phone. I think I made their day :chuckle