Medicine error

[arys1075]

Hi,

There was a nurse working in operating room. The surgeon ordered a certain medicine to the scrub tech. The scrub tech asked the circulating nurse to get it for him. The circulating nurse gave the medicine without clarifying the order to the surgeon but showed it and clarify it to the scrub tech. The scrub tech gave the medicine to the surgeon without label. The surgeon injected the medicine without clarifying it to the circulating nurse. The patient reacted to the medicine, The patient had PVC, hypertension, and tachycardia. It was the time the surgeon asked the circulating nurse what is the medicine?

In this incident the nurse failed to communicate with surgeon. Do you think only the ciculating nurse is the one to be blame in incident like this? Is it a ground for termination or disciple or suspension? Is there anybody who had a experienced like this? If you are the manager of this nurse will you terminate the nurse?

[GadgetRN71, ASN, RN]

Patients can have reactions to meds that previously gave them no trouble...in the case of allergies, I always clarify with the doctor as far as dosage, cross-reactions etc.

The circulator is the licensed person and I won't even give a med mixed in a bag of saline(irrigation, flushes) unless I mixed it myself. Now, should the scrub tech have labeled the med? Yes. Should the scrub tech state out loud what the med is before handing it to the surgeon?Yes. But, that still does not absolve the circulator, because he/she dispensed the med in the first place..The nurse should be clarifying the med with the doctor before it is dispensed.The circulator also should be having the scrub tech label the med. I believe this is the standard in most, if not all, ORs.

I can't speak as to what corrective actions may be taken in the above scenario...may be a write up, a verbal or termination if it's happened more than once.

[Scrubby]

OP: You haven't provided enough information to suggest that there even was a medication error so I'm confused. The patient may have reacted to what the surgeon requested anyway. So was it the wrong medication, dosage etc?

For my own practice if the surgeon is too busy to check the medication at the time, I verify with the anaesthetist and also keep all the vials I have opened so if any questions are asked I can produce the label.

I agree with the above that if an error is made then the circulator/scrub should be held accountable for their failure to follow policy. But I also feel that the surgeon is primarily responsible as they are the person who actually physically gives the medication. Surgeons should automatically check anything they give without having to be prompted by someone else.

I don't believe that a random medication error should be grounds for termination. This sort of draconic punishment IMHO can lead to a culture of blame where nurses/other health care professionals may not feel comfortable about being honest about their errors and cover them up. I believe that if a nurse makes an error then it should be a learning curve and opportunity for education. If someone is constantly making medication errors then I guess termination may be best for patient safety.

[linda2097]

Whenever I give a drug to a physician, I ALWAYS ask him, "is this the right drug?" even if I already know that it is the right drug. This forces them to look at the drug and confirm it.

You need to tell us the drug to help us decide how serious this incident is.

[arys1075]

Well, I can not tell the drugs, for the privacy of the involved staff.