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.

[inthecosmos, BSN, MSN, RN, APRN]

Multifactoral cause. Interested to hear what happens. There are many opportunities here for process improvement.

[red426]

Thank you so much, that does make me feel a little better.

[JKL33]

Is this situation being investigated via RCA or other process of examining all the issues besides the Cardene?

[CarolinaRN0501, MSN, NP]

Please, do not let this turn you away from nursing. Learn from it. Grow from it. Any nurse that says they have never made an error of some sort is lying through their teeth.

As several people have said already, there were a chain of events that lead up to this. I believe mrsboots87 laid it out perfectly though. My biggest one would be why wasn't a rapid response called if the patient was deteriorating? And your floor support is another issue I have. You should have a leader you should be able to go to for situations just like this.

[subee, MSN, CRNA]

OP, you didn't cause this code. Patient should have been cardioverter, IMHO.

[Been there,done that, ASN, RN]

On 1/25/2019 at 4:08 PM, red426 said:

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.

Then your question is answered. You did not cause the patient to code.

[Mini2544, ASN, RN]

Hi! I am very sorry this situation happened to you! I think my thoughts mirror the majority here....no the Cardene did not cause this pt to code. I work in an ICU and this patient should have had rapid response called and they should have been taken there. I am a newer nurse myself (a little over 1 yr experience) and it is always astounding to me how much stress and responsibilty is placed on bedside nurses. You sound like you work in a unit that doesn't have very good support and that is really unfortunate. Take up for yourself though, don't let the powers to be on your floor pin this on you. This is not your fault.

[Wuzzie]

I think we need to be careful that in our desire to support our colleagues we don’t forget that even when it’s the system that failed we are often part of that system failure. While I am not in any way saying the OP was the cause of this event there are certainly things that could have been done differently and it is important that we do not gloss over them otherwise no learning will come from it for the OP or those reading this thread. Rather than approaching it as a fault/no fault subject we need to look at it as what could I have done differently if faced with the same scenario. As I said in a previous post there is no way to say for sure if things had been handled differently the code would have been avoided but there is most certainly room for growth and honing of critical thinking skills. Every single time I have faced a situation similar to the OPs (and there have been a lot in my three decades of nursing) I try to go back over it to establish what went well, what could have been done better and what absolutely needs to be followed up on to improve things for the next go around. It is only by taking responsibility for our missteps, mistakes and errors that we grow as nurses. Our responsibility, especially us senior nurses, is to provide an environment that supports this learning, not blaming, culture for all of our colleagues. Think of how much change we can accomplish if we work together to help each other achieve our best.

[offlabel]

Amount aside, the cardene didn't have time to do anything, let alone cause the patient to arrest if your timeline is accurate.

As a Monday morning quarterback, the physician ought to have been thinking about a fluid bolus somewhere in there. Thats why esmolol is so useful in these situations...you can see if a beta blocker will actually help or not, and if it doesn't, it goes away anyway and you can give some fluid. If it does, something longer lasting like Lopressor can be given.

[murseman24, MSN, CRNA]

If the pt was deteriorating rapidly cardiovert would have been better. You were just following orders and doing what you thought would help. Rapid response anytime the pt is deteriorating like that should be a first call.

Doesn't sound like the Cardene caused the code, the pt sounded like they were crashing before that

[Wuzzie]

An interesting aside, well at least for me. I am more familiar with the use of Diltiazem in the emergent treatment of Afib-RVR rather than Metoprolol so i did some checking. There are some recent studies that suggest Diltiazem is the better choice as it is more likely to achieve rate control but what stood out to me was the discussion of giving Diltiazem after Metoprolol which seems to be frowned on. Apparently there is a theoretical and anecdotal concern that administering calcium channel blockers and beta blockers consecutively increases the risk of causing complete heart block. While this has not been studied it was suggested that if this was to be done it should be with a cardiologist present. Interesting that the physician in this case ordered a risky treatment OVER THE PHONE!

Things that make you go hmmmmm...?

[JKL33]

It sounds like (possibly) the first thing that went wrong was that he didn't tolerate the amiodarone.