Medication error

[EDRN32]

Hello all,

I work at one of the busiest ER's in the city. Very chaotic and disorganized. I have been a nurse for about 9 yrs and 6 of those I have worked in this kind of setting, so I would consider myself somewhat experienced nurse. Several days ago I had a very unpleasant experience of making a med error. Very dangerous one too and I don't even know how it happened. I was attempting to start an IV insulin on a pt that came with BS above 600. As I was setting up the pump my charge nurse was trying to move the patient ( and the bed ) to the other side of the room because the cardiac monitor on this side was not working. As I always use another nurse to check my insulin with me I asked the second nurse to verify it with me. ON my surprise when I looked up toward the insulin bag hanging more than 2/3 's of the bag was missing. The bag was spiked, tubing was of course primed and it was inserted into the pump. It was connected to the patient but I did not yet program the pump so I had no clue how the medicine could have gotten to the patient. Probably about 40-50 units have infused into the patient. We use Alaris pumps and I remember I had some trouble closing the door on one of the channels. I have administered IV insulin many times with the same pump never had this happen ( Thank God). Patient did fine. We monitored her BS every 15 min, gave her 1/2 amp of glucose and started her on D10 . She was admitted to ICU for monitoring but her stay was uneventful. She was moved to medical floor the next day.

Now my job ( and maybe my license) are in jeopardy. I already spoke to my boss twice but she is being very cautious as to what she says to me about this and she told me not to talk about this. She told me that I'm to expect some kind of corrective action ( not sure what this means) and that this is a very serious matter. I asked her if I'm going to be fired or if there will be any kind of action taken against my license and she didn't comment on this just told me " she wants me to be successful". She says there will be an investigation and she will talk to me next week.

I'm worried sick. I feel better knowing patient is ok but I can't even sleep at night knowing that I might lose my license. Even losing my job would be devastating for me because ER nursing is what I have done and what I see myself doing for the rest of my life. I'm a single mom and my job is the only source of income for me and my daughter. Not sure what I'm going to do if I can't do nursing anymore. My mind is going wild.

I would appreciate any kind of advice or if you have any thoughts about this please share. Anybody had similar experience or have heard of any?

Thanks

[morte, LPN, LVN]

Just curious, was that particular pump taken out of service? And if so, was anything found to be wrong with it? If not, if there is any way to identify it, it needs to be removed and checked out!!

that was my thought, as well. even before the doc of previous issues. needs to be done ASAP.

[BSN-to-MSN, ADN, BSN, RN]

Clamp the tubing if it's connected to the patient, and un-clamp it after programming the pump?

[Guest219794]

"The bag was spiked, tubing was of course primed and it was inserted into the pump. It was connected to the patient but I did not yet program the pump"

[COLOR=#000000]Per your description, there was no medication error. Assuming the pump was not running, this represents a mechanical malfunction.

And, relax about the license. The BON does not pull licenses for this stuff.[/COLOR]

[chare]

https://allnurses.com/critical-care-nursing/25000-mcg-of-1023583.html

[NickiLaughs, ADN, BSN, RN]

I've used alaris but I never connect to the patient until it's programmed because I feel I heard about this malfunction happening before. I agree with the others, it's mechanical failure not a med error. Your job shouldn't be punishing you for this. :/.

[iluvivt, BSN, RN]

First, you are NOT going to lose your license over this (so relax a bit) issue and secondly no harm came to the patient! It really just needs to be investigated to figure out what went wrong and the focus should not be to blame the nurse! Again, there were no damages to the patient and it was easily reversible and the powers that be need to be reminded of that an not make this a witch hunt!

Here are some thoughts : You could have had a tubing misload with your first clue being that you had a little trouble closing the door. If that ever happens again you need to reload it until the door closes with ease and even then when you hook up the IV to the PIV or CVAD, stay and make sure the pump is working as programmed. If everything was loaded correctly and you still had an an unexplained free flow then the pump should have been immediately sequestered with a high suspicion of a mechanical problem. I would have also written down the the model number and the ID number of the pump (maybe even snapped a photo or two and checked on the last date it was serviced. I would have also not trusted the tubing and would have sequestered that too! Sometimes it is the tubing that is not functioning!

As an additional safety strategy you can perform is to clamp your most distal tubing (usually the add on micro tubing or the attached micro tubing) and once the pump is fully programmed and you are ready to initiate the the program you then unclamp the distal tubing and then observe the drip rate and make sure it is consistent with what you programmed in. That way you are not trusting the pump to prevent free flow until it proves that it can be trusted and also that will alert you to a tubing misload. We all trust the pumps to deliver the rate as programmed and for the pump to work as excepted but they can and do fail so I have learned it is best to use additional safeguards especially with the initial set up. What Alaris model is it!

I sure hope your employer has some sense and handles this as a learning experience. Also a consideration is how your Biomed dept services their IV pumps. Are they serviced properly and if there was a problem identified with your model were they all corrected? You are smart to do a little research on this because it does sound like they are out to blame you and you may be able to talk some sense into them!

[Lunah, MSN, RN]

Clamp the tubing if it's connected to the patient, and un-clamp it after programming the pump?

That is what I do, every time. We use Alaris pumps. They are incredibly finicky! And after reading the recent threads here with issues, I am twice as paranoid about my pumps. Lol.

[morte, LPN, LVN]

never have absolute trust in a piece of equipment, they are all man made, after all. and not perfect.

[RNCEN]

Alaris has apparently had some serious issues with pumps doing this exact thing. We've had several where I work. Seems it wasn't through any fault of your own.

[onedayitllbeme]

I'm so sorry that happened. It is a reminder to me to always leave the clamp below the pump on until it is programmed and I see it dripping appropriately.

[srvjamz]

Thank you so much EDRN for being willing to write about this topic. we use Alaris pumps at our facility and I have many times struggled with the door situation. I always thought it was just me. If more were willing to do what you are doing.. all might have been averted for you as there may be a pattern here. Certainly equipment failure should be looked at.. Because of your generosity, I am going to be more careful in the future .. that being said..

1. have you heard yet about the outcome? I agree with many others here that BON rules should not reach for pulling your license as a first response and it makes me sad to think you must worry. Nine years of solid practice demonstates a great nurse who is human..

2. Since my tenure in the ED I have had two other learning opportunities to validate Sun0408 post that to STAY and WATCH to make sure things are working correctly is a good idea. One involved rapid blood transfusion where I forgot to clamp the saline bag when unclamping blood bag.. blood backed up but was still deliverable). Another was transporting patient to floor where O2 was hooked up but (according to floor staff) not turned on (have my doubts about that one but unable to prove). Although you did not actually leave this patients side as I had in my examples..

Thank you again