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Discussion

Med Errors

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.

Featured Replies

I'm a student nurse, and reading this thread has blown my mind! Of course, I knew that med errors happen, and even my instructors have told us they've had errors and what they were, what they did, and any repercusions (sp). Anyway, I have to say that I agree with a previous poster that questioned, "And they want to replace LPN/LVNs with CMAs, etc." Sure, LPNs/LVNs are diploma nurses and technically have less education than RNs, but they are trained and liscensed!

I actually caught an "error" if you will during clinicals a little while back. We are given the meds by the staff nurse, b/c neither students nor instructors have a password to the storage, anyway, the pt was supposed to have Digoxin. So, before getting the meds from the instructor, I went in and did vitals, HR was 80, so I went to get the meds. No digoxin in the baggie. When we questioned the staff nurse about where it was (we figured a pharm mistake, maybe), she goes "Oh, I already gave it. Did I forget to chart it?" Um, yeah! If we had had access to the storage, my instructor and I could have potentially given a second dose...

Oh, and of course we're still at the point where we have to repeat the 5 rights, except my clinical instructor requires a 6th- Allergies!

Thanks for all the free info though! :)

I'm a student nurse, and reading this thread has blown my mind! Of course, I knew that med errors happen, and even my instructors have told us they've had errors and what they were, what they did, and any repercusions (sp). Anyway, I have to say that I agree with a previous poster that questioned, "And they want to replace LPN/LVNs with CMAs, etc." Sure, LPNs/LVNs are diploma nurses and technically have less education than RNs, but they are trained and liscensed!

Oh, and of course we're still at the point where we have to repeat the 5 rights, except my clinical instructor requires a 6th- Allergies!

The Arizona Board of Nursing released the results of a pilot study of "Medication Technicians" or Med CNAs in 2008, exploring the idea of using them in Arizona.

Pre Med Tech average med error rate 10.4% (LPN - 10.12%; RN - 11.54%)

Post Med Tech average med error rate 6.6% (LPN - 7.25%; RN - 2.75%; Med Tech - 6.06%)

Interesting...

I have seen the "5 rights" turn into the "7 rights" then to the "10 rights"

This was told by my basic pharmacology teacher (who is a veternarian....just taking this class out of interest while on the waiting list for the nursing program.) Well, apparently someone broke into her clinic looking for oxcontin, and just saw a med with the word "oxy" and decided that they had struck gold. Needless to say, the criminal went to the ER complaining of horrible abdominal cramping.

  • Guides

The 5 Rights (6?7?8? etc) apply to medication administration whether you're a student or have been a nurse for too many years to count. Sometimes I think they are actually more important for nurses who've been doing it for a looooooong time over and over as it's much easier to let your attention wander. Students are hyper-aware.

Miss Julie you bring up what is a pretty common source of error - and that's when the responsibility for pulling, giving, charting, etc is divided over more than one person. If a nurse has sole responsibility for her patient's meds and waits to chart it not much will happen as long as she doesn't report off to someone else or leave without charting it. The nurse did not adequately communicate with you and should have thought about that when she took the Digoxin out of the baggie.

Asystole that is interesting! I'd love to see that - do you have a link? It looks like on the surface it's saying that error rates dropped when they got some help - not surprising, really. But RN error rates went from 11 something to 2 something percent? That's curious.

  • Experts

What struck me about that is that there are no stats for errors by tthe MED TECHS! It stands to reason that if the LPN/LVNs and the RNs aren't giving as many meds there would be fewer errors made. The law of averages, you know. But how about the TOTAL number of errors made psot introduction of the med techs?? (Who, by the way, would only have that one responsibility and not a hundred others competing for attention from the same brain...)

Miss Julie you bring up what is a pretty common source of error - and that's when the responsibility for pulling, giving, charting, etc is divided over more than one person. If a nurse has sole responsibility for her patient's meds and waits to chart it not much will happen as long as she doesn't report off to someone else or leave without charting it. The nurse did not adequately communicate with you and should have thought about that when she took the Digoxin out of the baggie.

I have to agree with this. The majority of med errors I have encountered recently (missed medications, not doubled doses), come from this scenario. Either a splitting of a shift or someone taking over a cart without proper communication.

Last night, I found an IV med error. I work at a SNF, and our meds come from an offsite pharm. The IVs were in a plastic bag, and the label for the ABT indicated that it was two different concentrations...it was given by four nurses before I found the error. Just goes to show...do the checks yourself, rather than rely on what others have done. You can't assume that they have all done it correctly, even though 99% of the time they have.

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