Medication error

[red426]

I made a medication error yesterday and I am mortified! My patient was in afib with rvr. HR = 200's. Very symptomatic. I had received an order from the doctor about an hour earlier to start an amiodarone bolus and drip and lopresser q 5 minutes for rate control for a maximum of 15 mg in an hour. I had run the bolus and had the maintenance drip infusing when the Patient became symptomatic. Prior to this he was not and hr was about 150. I gave two doses of the lopresser and called the doctor to let him know patient was getting worse. I was alone for all this, charge nurse and manager were in a meeting. Everyone else was with their own patients. Doctor told me to give last dose of lopresser and if no improvement start on cardizem drip. I transcribed the medication wrong and put in cardene by mistake. I by this time managed to catch another nurses attention and asked if she would help me. She told me she would call pharmacy and get the drip for me. She pulled the cardene and primed the tubing and connected to the patient. The IV pump started beeping that there was air in the line at the same moment the patient coded. I yelled for a code blue and we began CPR. He regained a pulse, was intubated and transferred to ICU. I am being reprimanded for the medication error. I feel awful! Do you think I caused this patient to code? I dont even want to be a nurse anymore.

[BarrelOfMonkeys, BSN, RN]

I know your mind is going a mile a minute right now. Understandable. I don’t have experience with this but I know others who do will chime in. I want to also say use this as a learning experience and I’m also glad the patient is alive. Mistakes happen.

[Wuzzie]

First of all...breathe. I wish I could offer you more than this but there really isn't any way to determine that you, specifically, caused this patient to code. It sounds like he was de-compensating so he might have coded anyway with or without the med error. We just don't know. But right now I don't think that is what you should be focusing on. There is a clear chain of events that led up to this unfortunate situation. Are you a new nurse? I ask only because it will help me determine how to approach this.

[JKL33]

I hope there is a lot more review of this situation (by your institution) than just the part about you getting reprimanded. Although cardene is now a part of this scenario, it can't be assumed to be the cause of the arrest.

Knowing whether (and to what extent) the cardene may have contributed is helpful for the future direction of the patient's medical care, but is much less relevant in processing the nursing piece of the overall situation in which you found yourself.

The patient is being cared for.

Has anyone offered you a (therapeutic) debriefing of any kind? You do deserve that.

[red426]

No, no debriefing.

[Been there,done that, ASN, RN]

Did the patient RECEIVE any Cardene?

[red426]

They determined if he did, it would not have been enough to cause the code. The only amount missing from the bag was just about enough to prime the tubing.

[mrsboots87]

Cardene is very vasoactive and requires very close monitoring and very frequent vitals checks. But this is a multi person error and not just you. The physician should be transcribing their own orders as this is a prime example of what can happen when they don’t. I know sometimes they can be away from a computer and you need a need fast. But as a regular practice, they should enter themselves. This is in part on that MD as well. Next, do you know what cardene is typically used for? That is your next step in realizing this was the wrong med during transcription. Cardene would not be used for RVR, but for HTN. Next, the nurse who spiked and hung that med should have asked what it is being used for. This med error is also on that nurse as she spiked and hung the med for you. It is her duty to understand what she is giving that med for. She should have questioned hanging it if you mentioned it was for RVR. Next, you should not be left in s floor with no support. Whether you are brand new or experienced, a charge or swat should be available for you to get help from and this is why.

Why was a rapid not called when the when the patient was still deteriorating while on amio? That part is neither here nor there now.

Basically own your osrt part of this error. Learn from it. Everyone makes errors, we just try our best to not make them and hope when we do, it’s not a fatal one. Unless that drip had been running for over 5 mins, it’s unlikely it would have caused the code. Do your best to be more prudent in your transcription and med knowledge next time and keep your head up knowing you are not alone in this. Also remember, you are not the only one at fault. Multiple people failed here. I only hope your facility does a complete review of this case so all involved get education in preventing this in the future. Penalizing you alone does not fix the bigger problem.

[Lunah, MSN, RN]

Stable patients get drugs, unstable patients get electricity. Sounds like this patient should have been cardioverted, perhaps?

Regardless, OP, please see if your employer has an Employee Assistance Program (EAP) if you need some help working through this. Or is there a hospital chaplain? No matter their (or your) denomination, I have found that they are typically great listeners in these types of situations. Take care.

[Ginger's Mom, MSN, RN]

A patient this ill needed a physician to see the patient, second the pharmacy should have questioned the order, it was a chain of errors you were just the last link.

[Seeing Myself Out]

Did you repeat back the order after the physician ordered it? I know in real life everyone is busy and doing that could get some unpopular responses, but in this case it could be beneficial.

[Wuzzie]

3 hours ago, Ginger's Mom said:

A patient this ill needed a physician to see the patient, second the pharmacy should have questioned the order, it was a chain of errors you were just the last link.

The last link, we’ll sort of. Let me preface this by saying that I am in no way saying the OP caused the code but as I mentioned earlier there is a chain of events that led up to the incident. First, this is a very new grad with, at most, 7 weeks of experience. Orientation should still be underway and I’m mystified why she was not being supervised while pushing drugs (lopressor) on a patient who wasn’t particularly stable. Second, no nurse no matter how experienced should be left on their own to handle this type of situation. The charge nurse should have been aware AND available. Third, is there no rapid response system in place? Calling/paging a doctor for a patient that is becoming unstable is a recipe for disaster when time is of the essence. What’s worse is it takes you away from your patient. Four, taking verbal orders is extremely risky, especially in an emergency situation. The TJC frowns on them and this scenario is exactly why. Fifth, generic vs trade name. Our facility uses the generic name exclusively. Although there are a few that sound alike by and large they do not and this decreases the risk of errors being made. We saw this in the Versed/Vecuronium disaster thread.

While it’s true that the patient could very well have coded if everything went perfectly there is also a chance that it might have been avoided had any part of this particular series of events been handled differently. The bottom line is that this is a classic case of a system break down. While the OP bears some responsibility, which she has very professionally accepted, she most certainly should not be blamed for a system that sounds like a setup for failure in the first place.

To the OP, talk about a baptism by fire! I truly feel for you but this is no reason for you to quit nursing! You were only a very small part of what happened. I highly doubt the patient got enough Nicardipine at the point that he coded for it to have caused it. That being said the transcription error is a big one that will likely stay with you for the rest of your career but that’s actually a good thing. This error, early on, will shape you into being an even better nurse if you let it. An experience like this should and hopefully will make you extra careful when it comes to administering medications, especially potentially dangerous ones. You’ve also now learned the pitfalls of verbal orders which will likely change your practice. Another important lesson is learning that you have a right and a responsibility to have support in new or unstable situation. A “right” in that your peers should be available to you and a “responsibility” in that you need to be able to recognize if you are in a situation that you need help. I feel like being aware of what my less experienced coworkers are dealing with in their assignments is a necessary and kind thing for me to be doing as a senior nurse. It is my hope that this experience will allow you to better advocate for yourself and your patients. You should never have been put in this position in the first place but you also need to not be afraid to say “I need help now”. Most of us have been in your shoes at some point in our careers. You are not alone. You are not a bad nurse. I agree with a previous poster, please seek out whatever help you have available to you. This is also something you shouldn’t be dealing with on your own. Be gentle with yourself. We are here for you.