Medical error prevention

[jxl377]

I have seen nurse run an bag of NS in a patient and 5 min later realized that the line was not flowing properly. We then needed to take care of the patient and help the person feel better. One way of preventing it would be to flush the IV with a 10ml syringe.

I am just curious to know what other medical errors (of any level) -other than medication errors- you have seen out there and how could it be prevented in the future.

[Esme12, ASN, BSN, RN]

IV fail all the time....I wouldn't classify it as an error.

What makes you ask about "medical errors" specifically?

[nurseprnRN, BSN, RN]

I have seen nurse run an bag of NS in a patient and 5 min later realized that the line was not flowing properly. We then needed to take care of the patient and help the person feel better. One way of preventing it would be to flush the IV with a 10ml syringe.

I am just curious to know what other medical errors (of any level) -other than medication errors- you have seen out there and how could it be prevented in the future.

1) I am not seeing the error here. Could you clarify where you think it is?

2) Are you a nurse, CNA, prenursing, or ... ?

[Meriwhen, ASN, BSN, MSN, RN]

I can't see the error either...unless something other than NS was ordered but NS was hung by mistake.

[jxl377]

I guess that's a bad example.

Just wondering if anyone can think of any errors.

[SaoirseRN]

There are many errors a person can make that aren't med errors, from minor to major errors. Really any time you are working with humans, there is potential for error.

I'm not sure what you are specifically looking for, but will try to provide a few examples.

1) The IV fluid might be ordered to run at 100ml/hr but the nurse could have it running faster or slower.

2) A post-op dressing might be changed by a nurse, when the surgeon has ordered it not to be changed until the next day.

3) A person requiring two people to assist with transferring could have a fall if a nurse attempted to transfer the patient without help.

4) A nurse might see their patient's O2 saturation of 88% and apply oxygen, but if the patient retains CO2, increasing the oxygen is an error and can be harmful.

Is that the kind of thing you are looking for?

[Esme12, ASN, BSN, RN]

I guess that's a bad example.

Just wondering if anyone can think of any errors.

What makes you want to discuss errors? Are you in school? Is this a homework assignment? Personal curiosity?

[Meriwhen, ASN, BSN, MSN, RN]

Well, given that you mentioned hanging a bag of NS, possible med errors for this scenario would include:

1. No IV fluids were ordered in the first place but it was still given

2. Something else (e.g., Ringers, D5W) was ordered but NS was hung instead

3. IV was set to the wrong rate

4. The NS/IV was ordered to be discontinued but the nurse didn't know/ignored that order

5. There's an incompatibility issue with NS and another medication being given (not really likely as NS plays well with others)

A malfunctioning IV line is not necessarily a med error.

[wooh, BSN, RN]

If you search the forums, there's LOTS of threads dealing with med errors.

[dudette10, MSN, RN]

TOO much reliance on the eMAR giving you a warning if something is amiss. We MUST do the five rights, regardless of the use of an eMAR, plus use our common-freaking-sense. For example: partial dosing of a unit dose container. Where I work, multiple dose containers prepared and labeled by pharmacy do not give a "partial dose" pop up on the eMAR. Error was made because of too much reliance on that pop up (and not thinking, "Hey, that's too much!"), and the whole container of multiple doses were given at one time.