Medication Error During A Code

[Nursethoughts123]

Hi everyone! Here goes nothing.

I feel if I write on here and share my story I’ll be able to help someone else as well as feel a little better. I just started working in the ICU in April (was on med surg for about 10 months before).

I’ve always wanted to be a critical care nurse and my dream came true! I just got off orientation last week, needless to say I’m inexperienced to say the least in this specialty. Still getting used to drips and medications I’m not used to and becoming familiar with doses, etc. Yesterday at work the census and acuity were so low we sent a nurse home leaving me and two other nurses which of one was the most experienced.

A rapid response (of course) was called at almost change of shift. I went upstairs and it appeared to be a patient in SVT or a fib RVR sustaining in the 180s. There were already many people in the room. I was trying to figure out what happened to the patient and if they were a potential candidate for the unit. Finally, the supervisor said, "no", and they were all set. I went back downstairs and the phone rang. 

That patient was immediately coming down to the unit as they were now unstable and there ICD had gone off multiple times. We set up the room and it was a MESS. This patient was at least in SVT for now an hour with no cardiac medications. One nurse was drawing up and preparing meds the other nurse (the charge) was recording and helping with other things and that’s all we had for help. So it was either I stepped up to the plate and took on the role of administration of meds as a novice nurse or this patient was in trouble . To the best of my ability, I tried my best.

The doc wanted an “amio bolts drip“ he did NOT say IV push 150 mg amio. The nurse preparing the medications handed me a bag of amio, line already primed. I saw the name but failed to look at the dose and programmed the pump after repeating to the doctor the dose of 150 mg bolus. The bag was more than half full when the charge nurse suddenly said this is all wrong who prepared this medication? I asked what was wrong with it, she said the concentration was wrong and the way it was set up. I was sweating. I had no idea what I did. I said the other nurse handed me the bag. I had programmed the pump to administer the whole bag, just like a bolus, but it was the wrong concentration up. I felt terrible the nurse was yelling in my face not helping any of the situation I stepped out of the way and said someone else should be taking over the medications.

Overall there were many things wrong with this situation.

A) the experienced nurse giving me the medication gave me the wrong bag ,

B) I failed to double check the dose, and

C) I should have stepped back knowing I was the novice nurse & volunteered to help with something else. Lesson learned.

Luckily it was caught early no harm was done. But I can’t help but shake this anxiety. At the end of the day I know I just need to move on and take it as a huge learning experience. 

Thanks for listening.

[Davey Do]

You have my respect and admiration for your method and endeavors in dealing with this situation, nursethoughts.

Mistake made, owned, and lesson learned. Your anxiety will inspire you to be a better nurse and will, eventually, subside. 

Someday this situation will merely be a story you'll share as a learning experience without the anxiety.

Keep on keeping on!

[NPOaftermidnight, MSN, RN, NP]

I remember so well what it was like as a new nurse in the ICU, I feel your pain! But the good news is that you are going to be a better nurse because of this. Mistakes were made on multiple levels here, the important part is that the patient wasn’t harmed. You’ll feel better about this as time goes on, but I guarantee you’ll never make a similar mistake!

[NightNerd, MSN, RN]

Hugs! You have exactly the right approach to this - you are willing to take this as a learning experience and will use it to make yourself an even better nurse. The mistake was caught and it didn't harm the patient, so breathe a big sigh of relief and give yourself a break.

[JBMmom, MSN, NP]

As you said, many things happened, it sounds like a difficult situation all around. No harm was done, and your practice will be stronger because we almost always make long lasting changes from mistakes. I think that in code situations, the amiodarone dosing is always one of the more challenging aspects because it can't just be made and stored on the carts. Perhaps management would learn from this experience and try to schedule more experienced people regularly, but probably not. Good luck!

[mmc51264, BSN, MSN, RN]

It sounds like there was no one leading the response. We always call out medication and dose when preparing and handing over and then again with time given. SVT for an hour? 

You did well. We can't be afraid to acknowledge challenges in ourselves and the system. 

[MunoRN, RN]

I don't think any phrase that includes "150mg" and "Amiodarone" can be interpreted as anything other than an amiodarone bolus during a code.  If a physician uttered this phrase and then failed to undue their order, whether it was intentional or unintentional, it's clearly not the nurse's fault if it ends up getting administered.

This is why we no longer allow Physicians to run codes.  Only Physicians can call a code, but they do not "run" a code and are frequently reminded to keep their conversations quiet if they insist on talking during a code.

[LibraNurse27, BSN, RN]

The bigger problem to me sounds like the SVT in the 180s for an hour with nothing done...? 

[Hannahbanana, BSN, MSN]

Doesn’t your RRT include a debrief period afterwards, or the next day, or monthly? It sounds as if this would be exactly the kind of thing for which these are standard— a chance to talk about what went well and what can be improved. Maybe the solution is as simple as not having the MD run the code, or a protocol for verifying and giving meds in a code that somebody hands you. Learning experience all around. 

[Nursethoughts123]

Right! No debrief at all the whole situation was just ridiculous and so unorganized . But yes 100% lesson learned .

[Been there,done that, ASN, RN]

Two big things to learn here. 

"The doc wanted an “amio bolts drip “ he did NOT say IV push 150 mg amio." Verbal orders require a dosage and a route.

" I said the other nurse handed me the bag". NO way is that an excuse.  Never administer any med prepared by someone else, unless you take a few seconds to review the order together.

Did  the patient survive?

[2BS Nurse, BSN]

This post makes me angry. Why are they leaving a newbie on a short-staffed unit administering meds during a RR without prior practice??  Also, no debriefing? No skills lab practice? 

Also, why can't physicians run codes?? Aren't they supposed to be calling the shots during a code?