Med Errors

I am just pre-nursing and this thread scares me to death. I know everybody is human and makes mistakes. I know I will always try to check and recheck every med. This thread really does open the eyes of us non-nursing (yet) Thank you

as nursing student nearing graduation was in OB rotation doc on ordered 25 mg of STADOL--teacher had drilled never give more than 4mg --- asked twice-doc screamed "I said 25mg STADOL"--did not do..went to RN--she came in to doc and touched her arm and made eye contact and very quietly said "do you really want 25mg Stadol" doc looked dazed and replied "I said 25mg demerol" we left RN gave ordered demerol. I learned a great lesson that day that I have used since--quieter voice gets attention.

My almost today:

had a little man getting a colonoscopy today. Order said 2liters of go lytely. My first go lytely experience. So the huge jug is in the fridge. I get it out. I ASSUME that it was the proper size, that he was to get the whole thing.

Well, no. the jug was 4 liters. his dose was 2 liters. the nursing assistant caught it. almost double dosed a little man. oops.

of course, another pt (not mine) had IV bactrim due to them. it comes in a 500cc glass bottle of d5w. same as IV amiodarone. bactrim was at 250cc hr for 2 hours. accidentally given the iv amio. whole bottle infused. (900 mg of amio over 2 hours)

I feel so bad for that nurse, b/c she must really be beating herself up over that. the bottles were identical, except for the pharmacy label. pt went bradycardic/hypoxic/hypotensive, had to be put back on ventilator (was already trached and previously vented) put on dopamine/dobutamine.

Argatroban hung as a IVPB and run over 1 hour (nurse didnt know what Argatroban was and assumed it was an antibiotic).

well, i learned something new. i didn't know what argatroban was.

Found a Zithromax 500 mg IV given by another unit. Zithromax in that amount should be hung with 250 ml bag of fluid to dilute, but this one was found with a 100 ml bag.

I worked with a resident who actually did a carotid ABG because the patient was a hard stick! Anyone want to guess the results???

I worked with a resident who actually did a carotid ABG because the patient was a hard stick! Anyone want to guess the results???

i haven't the slightest clue what that would do to the results. please share.

Well...Im sure the result of the ABG was correct when the patient was still alive but Im willing to bet that the patient didnt survive being stuck in the carotid artery for a ABG.....thats really pretty scary and its even more scary to think that when we're sick or when we get older we're going to put our lives in the hands of strangers also.

We keep stock meds in ziploc type bags for patients that come in after pharmacy closes (9pm-7am). Have found Nubain in the Narcan bags, vicodin in the motrin bags, and PNV in motrin bags.

Have seen 100mg demerol instead of 10mg morphine given IM - both are kept in baggies in same drawer and nurse not paying close attention

Motrin given on a schedule 08, 14, 20, 02 - pt. refuses 02 dose but wants it at 04 - then next shift gives 08 dose on schedule because of habit, despite being told in report that it was given at 04

Motrin given while patient on Toradol

After the recent posts on magnesium sulfate ODs and deaths, had a pre-eclamptic pt on mgso4 undergoing pit induction go back for a stat c-section. I made sure everyone in the room new about the mgso4 then I put a piece of tape across the dial and the cartridge door on the pump.

Not med error, but same type situation. 10 babies in nursery (one of our crazyest nights) Two babies being circ'd. Supposed to be done at 08, but doc comes in for delivery and decides to do hers at 0400. Doc known as a real ********, demanding and unforgiving. Both babies had very similar names, realized the wrong baby on the circ board half way through the circ. Thank goodness other baby was going to be circ'd that morning anyway, just done by a different doctor. Big investigation and now a change in practice including new consents with area for MD to sign acknowledgement that they properly identified baby prior to circ.

Hey is this still a good thread. I have to say that it has been very helpfull to me. I am a new nurse 1 yr only so thanks for all the great advice and I hope I wont make a mistake but I know that some day it will happen. I hope that I get the same support in person as you have given eachother on this site

I once gave Mr. E. Smith his wife's meds...(she was Mrs. E. Smith). Poor Mr. Smith got Premarin! The doctor told me not to worry about it and Mr. Smith came out of his room for lunch wearing his wife's flowery hat and had socks under his shirt at chest level. He was always a prankster. :)

I've made others, but this is one I will never forget.

Insulin freaks me out! I had a potentially bad situation to arise from the administration of the wrong type of insulin (Humalog instead of Lantus). Luckily this patient's blood glucose never dropped below 70, but it was enough for me to learn my lesson! Most facilities require that a 2nd nurse validate the insulin dose, but I work in LTC and it is not required. Pay attention!!!