Med Errors

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???

:chuckle

A certain nurse put ear wax drops in a patients' eyes thinking they were actually eye drops....pharmacy had just switched brands of saline eye drops and they looked almost identical to the ear drops. Patient ended up ok but ear wax drops have a stronger percentage of hydrogen peroxide than the regular kind that you use to clean wounds (or whatever).

So, don't get in such a routine that you don't check those labels.

Oral Tylenol or Motrin, I forget which, pushed through an IV line!!!

That patient certainly spent some unanticipated time in ICU!!!

And also... using ostomy paste for diaper rash ointment... oops :) I know the nurse who did this and she laughs about it now. She is a wonderful nurse.

Nurse leaves original order on MAR after pharmacy sent a different concentration of the same med. Med was given 2 or 3 days before someone caught the error. Fortunately no harm was done. Even though the concentration of the med exceeded what was to be given it turned out the resident needed a lot more of the pain med (res. dying and in a lot of pain and discomfort) and it was ok with family. Strange turn of event.

oral tylenol or motrin, i forget which, pushed through an iv line!!!

that patient certainly spent some unanticipated time in icu!!!

if i had a nickel for every patient that has said to me 'can't you put that in the iv', or if i could come up with the iv equivelant...i'd be a millionare!!!!

i guess you can't put it in the iv :smackingf :chuckle

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.

CseMgr, I understand the error & the faulty math that caused it. I'm just curious about the dosage of Dilaudid that had such an effect on the pt. -- what's the equivalent in milligrams to the 1/16 gr. that the pt. received? I work in the ER, and it's not unheard of for a pt. to get up to 8mg of Dilaudid IV within a few hours time. Just curious ...

BTW: I'm reading this entire thread word for word -- as a new RN this stuff is enough to give me nightmares. :stone

if i had a nickel for every patient that has said to me 'can't you put that in the iv', or if i could come up with the iv equivelant...i'd be a millionare!!!!

i guess you can't put it in the iv :smackingf :chuckle

i know... whoever someday comes up with iv tylenol or motrin, is going to be very rich! that would be such a good medicine.

This error wasn't made by me, but it occurred when I was working. We had a patient who got Theragesic cream (basically a very strong IcyHot) on her shoulders and under her shoulder blades before and after therapy. She also got buttpaste after every diaper change to the rectum and perineum. The tubes were VERY similar, and well... I heard the scream all the way down to my nurse station. NOT a fun situation!

I once gave my EMS partner Narcan via his conjunctiva. We were bouncing down the road with an unconscious overdose pt and we had just switched from prefilled Narcan to vials. I went to expel air from the syringe, the ambulance hit a bump and, although my partner was sitting on the bench seat on the opposite side of the pt, the trajectory and force were just right. I can't find anything about the ophthalmic absorption of Narcan, but my partner isn't into heroin, so it was a moot point.

Error waiting to happen: Res. has liquid potassium and lactulose in very similar containers. At first glance you couldn't tell them apart. KCL(7.5ml), lactulose (45ml). Can you imagine if they got mixed up?

[This quaternary care center of 650 beds and 8 ICUs does not have a pharmacist in house between 23 and 07 ever. If the med you need on nights isn't in your Pyxis, it might be in the "night cupboard". A security guard goes and gets it. Hmmm.

Just started work in psych. Our hospital of 200 beds has a pharmacist on at all times.

Note to all...

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. !

Sounds like Norwood Extended Care In Edmonton, though I realize it could be anywhere.

I know... whoever someday comes up with IV tylenol or motrin, is going to be very rich! that would be such a good medicine.

In the UK we do have IV paracetamol (which is acetaminophen-tylenol) and it is fantastic! Just waiting for Iv motrin