My first medication error-help!

Hands and Heart · Jul 17, 2008

I am so sorry this has happened to you and especially at a time when you are vulnerable and unsure about your skills and knowledge. As I am still in school at the moment, I do not know the ramifications that you may face and how this all works with you still in orientation. I am glad that your patient is okay. What we all have to learn from this is that although we may be precepted by a "seasoned nurse" we have to use our critical thinking and know the 5 rights of every medication we give. I think for any situation one has not had experience with, we need to slow down and put together all the facts of the patient situation, assessment, medication usage and dosage. Just taking a quick 5 minutes to think the situation through would be good. Medication errors will happen. We just have to do our very best to prevent them. Good luck to you.

Kyrshamarks, BSN, RN · Jul 17, 2008

90 mg of valium on a severe alcoholic over the course of a shift is not a lot of valium. It may seem like it is but I will lay odds he also had other drugs during the course of the day that potentiated the valium that he was getting. Hell, my brother takes 60 mg of valium every morning when he gets up thanks the the vaunted VA system that has made him addicted to it. He has been on it for 20 years and at one point was taking up to a 100 mg at a time as was ordered.

CitrusBeeRN · Jul 17, 2008

I am also a new grad, and I completely understand and relate to that feeling of feeling responsible for every little thing that goes wrong during a shift. So sorry you had to have an experience like this.

Reading your post made me wonder if your hospital has a protocol for alcohol withdrawl. The ICU I work in has a specific protocol for that, and I'll have to look at it to see what doses of benzos are listed. Off the top of my head, 10 mg of diazepam does not seem excessive, especially for an ETOH withdrawl patient.

You definitely did the right thing by questioning the dose and asking your preceptor. My thought is the dose was not inappropriate per se, just not right for that particular patient.

LovelyLucky · Jul 17, 2008

We do have a DT protocol to administer Serax. The patient was initally on Serax, and he was doing beautifully! Even though he was scoring high enough on the protocol to have the max dosage of Serax, the physician D/C'd the protocol because she didn't believe he was in alcohol withdrawal, and started the Valium. Plus, the guy was taking Xanax at home and they D/C'd that on admission. The charge nurse was pretty nice about it and told me that because he had no permanent harm done, I am not responsible. Everyone on the floor told me I was not responsible, and my manager has not said a word about the situation. My main concern is that I am going to be sued.

Smokey9283 · Jul 17, 2008

I would have to agree with the person that stated that something potentiated the reaction. The patient was on from what I can tell a oral benzo (serax) already and then of course was on the diazepam. Probably had some serax left in his body when was getting the valium. I also looked up the dosage on valium through IV push for D/Ts. What it said is, "may give 5-10 mg in 3-4 hours." Remember also that when the BON looks at a license or problem, they take into consideration the amount of experience that a nurse has and whether it is reasonable to expect that nurse to have known the full implications of their actions. Hope that this is somewhat help ful. When I was first precepting as a nurse, I gave the wrong insulin to the wrong patient and almost sent them into a diabetic coma. We are all going to make mistakes. I will never make that mistake again and I bet you will always pay special attention every time you have a patient on alcohol withdrawal.

DaMale Nurse · Jul 17, 2008

You really don't need to worry about being sued. First, you gave the drug as prescribed by a physician, you were to medicate the pt according to agitation and as you said the pt was agitated. It seems like a lot of Valium to give, but I have seen bad DT's and giving 5mg of Ativan (1mg of Ativan = about 4mg Valium) q hour and the pt still needed to be in restraints w/ a high temp. For a total of 40mg of Ativan for a 8 hour shift. I really don't see how this even was a med error. You gave the right dose, right patient, right medication. I would view this as a adverse reaction. The med change is a bit fishy but that is not within your scope of practice and no one would blame you for not questioning the doctors order. I wouldn't sweat this one. :nuke:

NeosynephRN · Jul 17, 2008

I am not sure I would have questioned that dosage on a ETOH withdrawl...our protocol calls for librium, but we do sometimes get supplemental orders for ativan or valium, espically in the begining. You were watching him and he was still symptomatic. As long as your preceptor was not trying to have you drug him so you would not have to "deal" with him, and he really needed it at the time, then I would say that you did the right thing. You would be amazed at the amounts of drugs some of these detox people need!!!

romantic, BSN, RN · Jul 17, 2008

I am a brand new RN. I just graduated in May and passed my boards one month ago. I am still in orientation. I am terrified I am going to be sued, and just needed some reassurance and advice. I was with a preceptor from a different floor the other night. I had never had experience with someone going through alcohol withdrawal, so I was pretty apprehensive and I had 5 other patients (two of which were post-op) I was caring for. There was an order for IV Valium 10 mg qhour prn. I asked my preceptor if that was a reasonable dosage, and she told me not to be scared that it was impossible to overdose someone having DTs and that there was no need to call to clarify the order. Well, to make a long story short, I am ashamed to say that I followed the physician's order. Every time my preceptor came by, she asked me if I had medicated him yet. By the time I left at the end of my shift, he was still agitated. However, when I returned the next night, the charge nurse came up to me and told me that they had to reverse the Valium, that the patient became unresponsive. I abseloutely sobbed. He received a total of 90 mg of Valium during my shift. The patient is doing fine now, they didn't have to intubate him or move him to ICU. Everyone reassured me that I was not responsible, and I overheard the wife telling the mother that "it wasn't the nurse's fault." But I haven't been able to get over it. I am so scared that I am going to be sued and so frustrated that I have had such an awful orientation. It's really making me question a lot of things. My question is, though I was working under a preceptor and am an orientee, am I legally responsible for this error?

Hi.

I hope this info can be of some help to you. According this info you didn't do any mistake.

(Saunders, Nursing drug handbook 2007, page 346)

alcohol withdrawal

IV, IM: adult, elderly: initially, 10mg followed by 5-10mg q3-4 hr.

So the max dose per day: 10mg+ 10mg*8 (q3hr)= 90mg/24hr.

I think that the patient developed an adverse reaction to this drug. It is possible that some other drug potentiated the action of Valium. During your shift did you notice some changes in the patient? Anyway, there is always place for an adverse reaction. In my opinion, you didn't do anything wrong. It can happen to any of us and we have to be ready for this.

LovelyLucky · Jul 18, 2008

No, during my shift there was no change. He slept for about 15 minutes after I gave him each dose and then he was right back to trying to pull out out the restraints. DaMaleNurse, I guess you are right that it wasn't a med error. Everyone just made such a huge deal about it.

Much thanks to each and every one of you for replying to me. I feel so much better now. :)

Cinqui73 · Jan 20, 2009

I agree - you gave it as ordered, therefore committed no error. Just make sure you document, document, document!

labrador4122, RN · Jan 25, 2009

I agree with everyone that you did not make an error, you asked your preceptor, and she said it was ok.

But even if you are in orientation and you are working with another nurse, if you do something, then you are responsible for that something because you have a license.

You are not working under anyone, you are being oriented to the job.

whatever you document is on you now----

when I started with my preceptor, I would write things on the chart that my preceptor told me, such as a telephone order--- and because I was new, I never questioned it, but now I never do that... if you talk to the doctor then you write it--

I used to write the order that she gave it, and write that I took the telephone order, when in fact I didn't talk to the doctor-------I know it's not a good thing to do now, but back when I was new, I just thought it was part of orientation. and never questioned it.