medication error

Nurses Safety

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Please please please help everyone....

Okay, I was working on a saturday in dialysis. One of the patient with end stage kidney disease came in set down and I was assessing her. After assessing her other nurse came to say hello to the patient because she is our new patient at our facility. This is her 2nd day with us. After assessment I was going to draw the heparin out of her PC line so i can flush her with saline and connect her to the dialyzer machine. instead, i got distracted by other nures.. I was chatting and forgot to draw the heparin out of the PC line arterial and venous line. I flush the line with saline and have connected the patient to the dialyzer machine then realize that i forgot to withdraw the heparin. oops! I was scared.. I wasn't sure if i did or not. I was confused. I did not tell anyone. The patient did not have any symptoms of reaction or side effect after 3 hours of dialysis. her blood pressure was stable. The heparin sodium was 50,000 units/1ml. so in the PC line was 1.7CC so that means 85,000units on each line that i flush with saline into the pc line.

I'm so scare.. i dont know what to do. I'm thinking should i quite this job?

I'm hoping to see the patient again in her next treatment because if i dont see her that means there is something going on with her and she might end up in the hospital. i'm so scare. i dont know what to do. :confused:

please help.. i need advice. i dont know what is the right thing to do right now.

Specializes in Mixed ICU, OHU.

ALWAYS report medication errors, PERIOD.

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the vials is 50,000 units/1ml... the patient port read 1.7cc on the venous line and arterial line. Therefore, 50,000units/1mlX 1.7ml= 85,000 units on each port right?

Yes, this heparin is use to instill into her port after dialysis. Untill when she comes back we need to withdraw it out of the port and then flush with the port with saline before connect her to dialysis.

while i was distracted by another nurse, i totally forgot to withdraw it.

I could not sleep because i don't know what to do. I'm a new nurse. I just recently graduated and still on trainning.

the reason why i'm not sure if i did withdraw the heparin or not is because i feel i miss the first step.. which is drawing the heparin out of the port before instilling the saline..

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Specializes in Trauma Surgical ICU.

You are talking in circles.. First you have to admit the mistake.. You did forget to withdraw the the heparin..

your words...while i was distracted by another nurse, i totally forgot to withdraw it.

Talking circles... your words...the reason why i'm not sure if i did withdraw the heparin or not is because i feel i miss the first step.. which is drawing the heparin out of the port before instilling the saline..

Learn from this.. take your time and always think of your pt and report errors as soon as they are discovered.

Yes, we have or will make mistakes, its human. But those errors need to be reported for the safety of our pts as well as possibly saving the same mistake from happening again.

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Specializes in Nephrology, Cardiology, ER, ICU.

Can I ask if you are in the US? There is no way any dialysis unit has 50,000unit/ml - that's just not even kept in stock. Way too dangerous.

The usual concentration of heparin is 5000units/ml or even 1000units/ml.

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Specializes in OBGYN, Urogynecology.
Can I ask if you are in the US? There is no way any dialysis unit has 50,000unit/ml - that's just not even kept in stock. Way too dangerous.

The usual concentration of heparin is 5000units/ml or even 1000units/ml.

We do have 10,000u/ml in our clinic but that's the most concentrated I've seen.

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Specializes in Rehab, critical care.

No offense, but the right thing to do would have been to own up to the mistake right away so the patient can possibly be spared any harm that could have resulted rather than just hoping they are okay. I'm sorry this happened to you, but owning up to the mistake right away could have mitigated any problems....you call the MD right away, explain what happened, and they order protamine or maybe nothing. But, now....you're just left wondering if the patient went home and went into DIC or something. I hope everything ended up okay with the patient. The important part with medication errors is to learn why they occurred so they don't happen again....so now you know the importance of what you are doing, and will try your best not to make small talk during this process.

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Specializes in Med-Surg.

50,000 units? I dont think I have ever seen this concentration before? Do they even use this dosage?

Im sorry for youre mistake and the emotional distress you are experiencing at this time... HOWEVER, you are a licensed professional.. and youhave the duty to report any mistake or error.

I understand you may be scared to report it because you are a new RN... you are afraid of losing your job etc. but THIS IS NOT ABOUT YOU ANYMORE. This is a patient safety issue. The mistake was made yes... but you are a grown adult, be responsible, be a professional.

and remember, we are all human, we all make mistakes.. and we all hope to learn from them :)

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As a previous dialysis nurse, you would definately know if you have drawn off the hep as these 2 syringes should be discarded accordingly. If you are questioning whether you have done it or not then more then likely you didnt widthdraw the 2 lomens. As there have been no adverse affects to the pt I would definately report it either to your preceptor or charge nurse. I would write what happened, was there any adverse effects to the pt. Once you realised the error occurred what you did. How you felt and what you learnt from the experience. Might help to put what you have done to ensure that this event does not happen again. go prepared so that this shows initiative and that you are willing to learn from mistakes.

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thanks to all the replys..

Today i went to work and the patient did come back for dialysis.

I also recheck to heparin vial and the label reads 50,000units/10ml in big writting and 5,000units/1ml in smaller writting.

Today we did monthly lab draw on all of the patients. so the patient did get her lab drawn today.

What had happen made me more aware when doing the procedure. I have learn from my mistake not to talk and pay attention to what i'm doing.

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So basically you are NOT going to report your error because the patient is OK? I find that reprehensible. I hope to God that I am never in need of care from a nurse like you. You are a danger to this profession. All I can say is thank God that poor woman is alright.

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So basically you are NOT going to report your error because the patient is OK? I find that reprehensible. I hope to God that I am never in need of care from a nurse like you. You are a danger to this profession. All I can say is thank God that poor woman is alright.

actually, I did reported yesterday when i went back to work. I learn from my mistake. I'm a human being also and I have feelings. I'm a newly graduate and just didn't know what step should I take. I'm sure some of the new graduate out there made mistake. Even Nurses who have many years of experience still make mistakes.

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Specializes in Mixed ICU, OHU.

Good job. Now you know to triple check and take care when you are using medications :)

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