medical mistakes

[labrador4122, RN]

i am a big beliver that you learn by making mistakes. some mistakes are obviously bigger than others. and as humans we are never perfect, and we don't live in a perfect world.

now that i have been working for 8 months, i can say that i have made a few mistakes myself. one time i did not give the scheduled pain med for my patient ..... (i can honestly say i do not know how i missed it, according to the computer it said it was a round the clock med when in fact on my paper med sheet it was a prn order--- and that was concidered a medical error).

i put up a bag of normal saline instead of an lr bag for my patient-- (the little bags look identical!!).

just to name a few------- but nothing that would kill any one of my precious pediatric patients.

last night, i heard a story that a couple of years ago, a nurse in the oncology floor was giving a chemo drug to my patient-- the nurse 1 had nurse 2 witness the chemo. nurse 1 gave 4x's the ordered dossage of chemo to the patient, the patient died, nurse 1 lost her license, and nurse 2 went on probation.

i know that working at night it's hard for us, but we still need to be on our feet-- not only to keep our licenses -- but for the sake of the patient's lives.

sometimes, my co-workers tell me "don't worry. i don't have to look at it" .... (talking here about my morphine that she needs to witness me). but evenso, i still make her look at it before giving it to the patient. after all, she has to signed that she saw it.

i like hearing stories like this because it helps me learn more so i don't make those mistakes. and perhaps, the hospital should have classes or medical error classes where mistakes are shared with us new nurses so we don't make the same mistakes.

[BinkieRN, BSN, RN]

Where I work it is mandatory that 2 nurses sign off on insulin, blood, PCA set ups or changes to dosages and other critical meds. I am very happy that it is mandatory. I have personally checked after two new nurses who drew insulin up in TB syringes If it's not mandatory at your hospital...suggest it. If not continue to be vidual about having another nurse check behind you. You're awesome!

BTW Over 200,000 people per year lose their lives as a result of errors which occur in a hospital.

[mscsrjhm]

When working hospitals-I can get insulin checked by another nurse. When working LTC-there is usually no other nurse available. I have had to use TB syringes for insulin administration when no insulin syringes were available, and it is one of my biggest pet peeves.

Just the other day, at a major hospital, I witnessed two nurses haphazardly checking blood at the desk. One was the charge nurse. In front of the nurse manager for the floor.

Agency nursing is so eye-opening.

Most mistakes I have been aware of or witness to have been due to overload. Too great a work load, too little time, and no assistance from co-workers or administration.

So very glad that I never make mistakes.

[ChocoholicRN]

I one time gave pain medicine by the wrong route. Dilaudid IV instead of PO, so the concentration was 4x what the patient was supposed to get. Luckily this barely touched the patient (sickle cell, she was used to that much pain meds) and she was fine, no harm done to her. It wasn't even my patient, I was covering for the nurse and the patient called twice for pain meds so I medicated her. Not going to go through all the details, but the med was labeled wrong in Pyxis and when it should have opened the drawer with tablets, it opened the injection. I didn't follow my 5 rights and ended up making an error. Just reiterated (sp?) the fact that its important to slow down, always follow the 5 rights, and when in doubt (or just for reassurance) have someone else check for you.

[pagandeva2000, LPN]

Where I work it is mandatory that 2 nurses sign off on insulin, blood, PCA set ups or changes to dosages and other critical meds. I am very happy that it is mandatory. I have personally checked after two new nurses who drew insulin up in TB syringes If it's not mandatory at your hospital...suggest it. If not continue to be vidual about having another nurse check behind you. You're awesome!

BTW Over 200,000 people per year lose their lives as a result of errors which occur in a hospital.

This is 'mandatory' at my hospital, also, but it is not routinely done because not many people have the time. In fact, our computer system will not allow you to sign for such medications unless you place someone's name as a witness, and you can literally place anyone's name down as a witness, which is equally as dangerous...because you can be pulled to court for something you are not aware of. I think what they should do to force this issue is to make it where both nurses have to add their private password to ensure that this is done properly.

[PICNICRN, BSN, RN]

The PICU where I began my career we had a VERY specific policy on who was to do what in a code- codes in this place ran like a fine tuned machine! Well, one holiday evening, my "pod mate's" patient who had been circling the drain all day finally did it! We had a new fellow who was in his first week on the job- wonderful and a great doc. So all is going smooth and we got a perfusing rhythm back and the pt started seizing- Fellow orders dilantin. I drew up the dilantin and the resident took it out of my hand. I said to her "let me get some tubing" thinking she would hand it to the bedside nurse- Which our policy stated that the bedside RN should be the only one pushing meds PEROID---- well..... about the time it took me to reach into the drawer and pull out the tubing, we hear "DILANTIN IS IN"!!! OMG- this resident just PUSHED the dilantin!!! The bedside nurse pushed her out of the way and tried pulling back on the central line to no avail. Let me tell you, in the side effects when they say "irreversible asystole"- they mean it!! We never got a heart rate back.

Moral of the story....... ALWAYS follow policy!!! If it is double checking with another RN then we MUST actually do this--- every time!, even if it is inconvenient. It not only keeps our patients safe... it keeps us safe too!

[Bumashes, MSN, APRN, NP]

I think what they should do to force this issue is to make it where both nurses have to add their private password to ensure that this is done properly.

That's how it's done at my hospital. We have an Omnicell, which holds all of the meds and keeps track of how many there are in each individual bin. You type in your username and password, select your pt, and then select the meds you need. Then the appropriate drawers slide open and you take your meds out of the indicated bins. If you take out narcs or other controlled meds, you have to count the amount in the bin and enter it into the computer. If your count differs from what should be in the drawer, it will ask you to recount. If it's still different after you recount, then it lists the last person to count the bin, and you have to get the charge nurse involved to sort it out. It does this with meds that need to be wasted also. If the Omnicell has my pt programmed as receiving 2mg of Dilaudid, and the vial comes with 4mg in it, then you have to have another nurse sign in to say she witnessed you waste the other 2mg.

[rhondaa83]

This is 'mandatory' at my hospital, also, but it is not routinely done because not many people have the time. In fact, our computer system will not allow you to sign for such medications unless you place someone's name as a witness, and you can literally place anyone's name down as a witness, which is equally as dangerous...because you can be pulled to court for something you are not aware of. I think what they should do to force this issue is to make it where both nurses have to add their private password to ensure that this is done properly.

That is the way it is in the LTC that I work at, and I love it. You have to have someone else there to type their password in, I can't understand why It would not be mandatory for everyone to do that.:twocents: Rhonda

[Beaches10]

Ok, so just what meds are required for double check? We of course still do Insulin and chemo drugs - what other common drugs is everyone else double checking. BTW can you tell me about that Dilantin situation. Moving into a new unit and see you can push it (peds are different) but tell me the restrictions other than max of 50mg/min in the adult population.

[pagandeva2000, LPN]

Ok, so just what meds are required for double check? We of course still do Insulin and chemo drugs - what other common drugs is everyone else double checking. BTW can you tell me about that Dilantin situation. Moving into a new unit and see you can push it (peds are different) but tell me the restrictions other than max of 50mg/min in the adult population.

Insulin, Heparin, Potassium, Magnesium to say a few.

[pagandeva2000, LPN]

The PICU where I began my career we had a VERY specific policy on who was to do what in a code- codes in this place ran like a fine tuned machine! Well, one holiday evening, my "pod mate's" patient who had been circling the drain all day finally did it! We had a new fellow who was in his first week on the job- wonderful and a great doc. So all is going smooth and we got a perfusing rhythm back and the pt started seizing- Fellow orders dilantin. I drew up the dilantin and the resident took it out of my hand. I said to her "let me get some tubing" thinking she would hand it to the bedside nurse- Which our policy stated that the bedside RN should be the only one pushing meds PEROID---- well..... about the time it took me to reach into the drawer and pull out the tubing, we hear "DILANTIN IS IN"!!! OMG- this resident just PUSHED the dilantin!!! The bedside nurse pushed her out of the way and tried pulling back on the central line to no avail. Let me tell you, in the side effects when they say "irreversible asystole"- they mean it!! We never got a heart rate back.

Moral of the story....... ALWAYS follow policy!!! If it is double checking with another RN then we MUST actually do this--- every time!, even if it is inconvenient. It not only keeps our patients safe... it keeps us safe too!

So, the patient died? What was the outcome? I hope that the nurses didn't get the can behind this...

[ilstu99]

Ok, so just what meds are required for double check? We of course still do Insulin and chemo drugs - what other common drugs is everyone else double checking. BTW can you tell me about that Dilantin situation. Moving into a new unit and see you can push it (peds are different) but tell me the restrictions other than max of 50mg/min in the adult population.

Signature double and triple checks are required for all IV fluids, insulin and any narc. But it's not uncommon for someone to say, "Okay, the order reads THIS....I have a syringe with THIS in it, and I'm going to infuse it over THIS. Yes?"

Our patients are so little and so fragile....a very small error could cause very huge problems. I think I probably check meds 15 times before any administration.