Hi all, I just started working in an outpatient PACU and I already made a mistake =( 7 years as a nurse and the only med error I've ever made was giving 200mg IV thiamine instead of 100mg. I'm used to drawing up only the amount of a med I'm giving and wasting the rest. So if giving 25mcg fentanyl from a 100mcg/2ml syringe, per hospital policy I would just draw up the 0.5ml and waste the rest. Then if I need another 25mcg, do it again. I know it wastes medication but that is how we did it, never walked around with fentanyl in our pockets.
Here there are orders for fentanyl 25mcg q 5 mins up to 150mcg. Their policy is pull the whole 2ml, give 0.5ml at a time and waste what is left. I feel nervous pushing in only a portion of what's in a syringe, and about holding on to a syringe with narcotic in it. They do have a box you're supposed to lock the syringe in for the 5 mins between doses but no one uses it. I was doing OK when they had 3ml syringes because it was easy to see the markings for 0.5ml, but now they ran out and today I had to use a 5ml syringe with no clear markings other than each 1ml. I wanted to just draw up 0.5 at a time but they said we can't re-access the vial even if clean w/ alcohol pad. I drew up the whole 2ml and when trying to push in 0.5ml accidentally gave almost 1.5! so pt got 75mcg instead of 25mcg. Pt was fine and ended up getting another 25mcg anyway, but I still let the manager know. He was very nice about it, and said it's OK to draw up 0.5 at a time and re-access the vial. He said just don't do it again but don't freak out or beat yourself up. I am so embarrassed to mess up on week 3, but glad pt is OK. What do you think of this protocol and how bad should I be feeling? I usually blow things out of proportion so need perspective!
