Medication error

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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.

Specializes in Tele, ICU, Staff Development.

The first thing I think of here is- the doctor should have put in his own orders.

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22 hours ago, subee said:

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

Yeah...missed that unstable part...Once that condition exists, especially outside of an ICU, rapid response request or, short that, call a code and synchronized DCCV.

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So, all of this happened on the floor? Why was a cardene gtt sent to the floor?

There is honestly all kinds of wrong with this, the least being a nicardipine gtt that almost got to the patient. The physician that allowed this to occur and was not at bedside needs reprimanded.

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It is a sad commentary that in the rush to judgement, a rash grab at a red herring drug error leads to blaming the nurse for an arrest in a patient that is clearly peri-arrest with or without the drug in question...somebody with a clipboard and a whistle did their job I guess...

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We are here to support you. We’ve probably all been in a sticky situation. Everything with this situation seems so wrong. First off the patient sounded like they should have been an ICU patient once their heart rate was that high and that symptomatic. Especially if a powerful drug like amio and lopressor are seeming to do nothing, but the patient is declining. This should have sent off a red flag for the physician for the patient to be transferred or get a physician to lay eyes on this patient. I am assuming you are a floor nurse likely with somewhere in the realm of 3-4 other patients depending on staffing. Likely step down unit by the drugs you are administrating. By all means I am a nurse and I get it, but I have learned by experience that your mind is running a mile a minute, but these are people lives in your hands. You have to slow down your mind in these situations and double check everything. This is a time that errors are made. Even though the doctor is trying to try a different medication like cardizem it takes time to work. Usually requires a bonus via IV push then the drip started. Too long for this critically ill patient. Please remember that! And if your patient is that symptomatic and there isn’t enough hands to assist you DONT EVER BE AFRAID TO CALL A RAPID RESPONSE. Trust me in that the rapid response team would rather you call them while the patient is responsive and not coding. As the nurses generally on this team are experienced and will understand. I’ve never been or seen anyone giving a hard time over calling a rapid. I always think of it as what if I were the patient (which I do I have a fib at the age of 28 with a rate in 300s that require electrical cardioverisons I have went into flecanide induced v tach. I have went into runs of v tach without medication cause.) what would I want my nurse to do or if I was the family member. I seen a post that you were a new grad. This Patient shouldn’t have been assigned to you. Even if they were stable prior and they switched to critical condition, charge nurse should of had an assignment switch. I agree you were very small piece of the puzzle in what happened to this patient. Pharmacy is supposed to cross check everything with that drug especially that serious. I worked a step down unit and we were not allowed to give that drug for acute hypertension and chest pain they had to the icu. Remember pharmacy has access to all your notes, patients lab work, and vitals. A proper review would have likely warranted a phone call to you from pharmacy and you would have realized you entered the wrong drug. Unfortunately this was a terrible chain of events for the patient. However I do NOT believe even for a second what possible litter Cardene enter the catheter of the IV caused this patient to code. The aib (it even underlying medical diseases) caused this patient to flip into a lethal rhythm or cause a clot which lead to the code. This was a big time medication entry error, however the medication was not given. Should it be classified as a medication error probably if you started the IV pump bc luckily the nurse didn’t have it primed all the way or correctly causing the medication not to enter, but if she didn’t prime it right it would have. That is just a really big learning experience and I can almost guarantee that will never happen again in your nursing career you will make sure of it. You worked really hard for your nursing degree and landing a job. I do not believe you should throw your career away over this, but use this as a tool to make you a better more cautious nurse. With time you will feel better. I know it doesn’t feel like it now, but you will. We’ve all got down ourselves over mistakes or things we did or didn’t do or say as Nurse’s. But we learn and move on. Do not blame yourself for the patient getting sick and coding. That’s not fair to you. You will have a meeting with the quality team, but it’s nothing to be intimidated about. They will just review the situation and you will tell your story and they will ask you how it could have been different. How to come to better outcomes etc. let them know everything we all said in this thread. It will take them by surprise and be an eye opener. If the doctor and pharmacist are with you don’t be afraid to stand your ground bc they won’t theirs. Again you will heal from this. And try to think about all the positive things you done to help patients and the comments you have gotten. Sorry so long

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I am so sorry this happened to you. Don't quit nursing but learn from this experience. Try to distract yourself and surround yourself with family and friends . I know how you're feeling. What is done is done. Now, you have to think of your future. Think strategically. You cannot go back anymore. I know it's hard. Make sure you write everything that you remember happened. Save any documentation you have from that day. Do you have a strong union representation at your facility? some unions don't help. Be aware of that, ask people who have been there for a while if the union is strong or not. If your manager/HR calls you in for a meeting, tell them you want a union representative. If your union is weak, get a lawyer, consult one. You're not alone in this, be strong.

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