New grad, Med error

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So I’m a new grad still on orientation. Long story short I was taking care of a pretty critical patient the other night. I was taking frequent verbal orders from the provider. The patient was vomiting frequently and had prn zofran ordered. The provider wanted me to give a dose so I went into the Pyxis and began to pull the zofran, 4mg. As I was in the process of removing the vial, the provider came into the Pyxis room and told me to give 8 of zofran. Not thinking this through, I pulled an extra vial. I drew up 8mg of zofran and gave it IVP to the pt. When I went to scan the vials after I had given it, I saw the order had been put in for 8mg IVPB. I was then told that I shouldn’t have given it IVP as anything over 4mg should be diluted. I am not placing blame on the provider, ultimately it was my fault for not following the correct administration process. I was confused by the provider and the multiple verbal orders, but it was still on me. I reported this immediately to my charge nurse. My question is, what should I expect to come of this? While I’ve heard of nurses being terminated for less than this, I hope to take this as a learning experience and not lose my job over this. There wasn’t any patient harm, and I’m extremely torn up about this. I just need some words of wisdom. Thank you!

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You are not going to get fired. It is okay. It is important to read up on any medication or dosing that is unfamiliar to you, even in time-sensitive scenarios, make use of your administration manual. It is worth noting that Zofran is actually a high-risk medication and you should always analyze risk factors for QT prolongation (other meds, cardiac hx, ect.) as I have heard of patients going into Torsades due to this med combined with other QT prolonging medications. You can definitely push Zofran, 4mg or 8mg, just ensure you follow the administration guide and push it over the required time. I believe minimum time is 2 minutes. A tip - if this patient is critically ill it isn't worth standing there pushing a non critical med like Zofran, just slam it into a bag and run it as fast as you can into the pump.

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Specializes in ICU, ER, Home Health, Corrections, School Nurse.

I've given Zofran a million times (well maybe not a million) and I don't think I would have known not to push 8 mg. I just did some googling, and found that you can push 4-8 mg over at least 30 seconds. If I had a patient that weighed 350 pounds, I wouldn't think twice. However, your facility may have it's own rules. Also in older patients, or patients with renal impairment, you may have to do even the lower doses as a piggyback. I can't imagine this would be a fireable offense.

Just a FYI for future reference: I almosty never fast pushed anything. There are too many drugs that can have a bad effect from a fast push, and with so many drugs having different directions (push over 30 seconds, push over 2 minutes, etc) I slow pushed just about all my meds.

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Specializes in Oncology, OCN.

I work oncology and IV push 8mg zofran frequently, though we do default to diluting all IV push meds anyways. Sound a little over reaction to fire over that. What sounds odd to me is that you can take a verbal order and just grab the medications and dose the pt without scanning prior. I can take verbal orders but have to enter them in EPIC, wait for pharmacy to review and verify before I would be able to even remove the medications from the accudose. Then it’s always scan the pt and the med before dosing. Our pharmacists are usually pretty quick to verify new meds but if we are in a hurry we can call them, day time there is almost always a pharmacist available on our unit as well. Very nice for bouncing questions off of as well.

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1 hour ago, Quota said:

I work oncology and IV push 8mg zofran frequently, though we do default to diluting all IV push meds anyways. Sound a little over reaction to fire over that. What sounds odd to me is that you can take a verbal order and just grab the medications and dose the pt without scanning prior. I can take verbal orders but have to enter them in EPIC, wait for pharmacy to review and verify before I would be able to even remove the medications from the accudose. Then it’s always scan the pt and the med before dosing. Our pharmacists are usually pretty quick to verify new meds but if we are in a hurry we can call them, day time there is almost always a pharmacist available on our unit as well. Very nice for bouncing questions off of as well.

This is where I went wrong in my part of the administration. The patient was actively vomiting so I thought I would give the medication and then scan it when I got a chance. I didn’t wait for the order to populate in the computer. It is my fault, I get that. I needed to slow down

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I find it interesting how you guys have orders on how to administer medications. At our facility the Docs order the medication and its up to nursing to decide whether to push, piggyback, ect. And how fast to administer. There are some exceptions where Docs will order to administer over a period of time (Mag sulfate, Ca gluconate, blood, ect.) though. Honestly props to you for reporting that because I'm not sure I would really consider that an error, maybe I would have written a note in the admin box "given IV push d/t Pt conditon" and left it at that.

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Specializes in Critical Care; Cardiac; Professional Development.
1 hour ago, Nickc58 said:

This is where I went wrong in my part of the administration. The patient was actively vomiting so I thought I would give the medication and then scan it when I got a chance. I didn’t wait for the order to populate in the computer. It is my fault, I get that. I needed to slow down

Yikes. Never ever EVER do this. Ever. Never.

Additionally, you need to slow your provider down. There should be closed loop communication in a situation like this. That means they give the order, you repeat it back to them and they acknowledge that it is correct.

Doc:"Give 8 MG Zofran IV"

You: "I am pulling 8 MG of Zofran to be given IV Push, correct?"

Doc:"No, dilute it and give it IVPB"

You: "That's 8 MG of Zofran in 50 cc of NS, is that correct?"

Doc: "Yes, that is correct".

It doesn't take long and it can save lives.

Breathe. I would be super surprised if you get fired over this.

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On 11/4/2019 at 6:44 AM, Nickc58 said:

So I’m a new grad still on orientation. Long story short I was taking care of a pretty critical patient the other night. I was taking frequent verbal orders from the provider. The patient was vomiting frequently and had prn zofran ordered. The provider wanted me to give a dose so I went into the Pyxis and began to pull the zofran, 4mg. As I was in the process of removing the vial, the provider came into the Pyxis room and told me to give 8 of zofran. Not thinking this through, I pulled an extra vial. I drew up 8mg of zofran and gave it IVP to the pt. When I went to scan the vials after I had given it, I saw the order had been put in for 8mg IVPB. I was then told that I shouldn’t have given it IVP as anything over 4mg should be diluted. I am not placing blame on the provider, ultimately it was my fault for not following the correct administration process. I was confused by the provider and the multiple verbal orders, but it was still on me. I reported this immediately to my charge nurse. My question is, what should I expect to come of this? While I’ve heard of nurses being terminated for less than this, I hope to take this as a learning experience and not lose my job over this. There wasn’t any patient harm, and I’m extremely torn up about this. I just need some words of wisdom. Thank you!

There is a reason that verbal orders are highly discouraged. There are urgencies and then there are emergencies where someone is going to suffer death/disability/loss of life or limb unless the medication is delivered in a more timely manner than the usual process allows. You must be able to determine which is which, and then you must follow through with the appropriate response. I don't know or need to know the details of this patient situation; I'm just putting that out there: Resist the temptation to alter processes out of a sense of urgency (often exaggerated), and understand that even in a bona fide emergency there are steps that simply can't be skipped.

As is laid out in the post above, if you absolutely must take a verbal order, you must take a complete order which includes all necessary information and then repeat it back completely, and then receive clear confirmation. Then follow your facility's procedure for what you do next (enter it into the computer, etc.).

You did not take a proper verbal order (and you did not look up something with which you were not familiar). When/if you discuss this with management, you will want to have reflected upon these things, and have a plan for how to make sure they don't happen again.

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I work in an ER.

I often

  • Take verbal orders
  • Push Zofran, 8 mg
  • Medicate before scanning

There was no harm to the PT. Why would somebody IVPB Zofran for an actively vomiting PT?

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Specializes in Fall prevention.

You said you are still on orientation so where was your preceptor during all of this they should have been helping you. I have precepted a lot and never let my nurse get in a situation like this even on their last day with me. I doubt you will be fired especially if no harm came to the patient. Take this as a learning experience and move on

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Specializes in orthopedic/trauma, Informatics, diabetes.
9 hours ago, canadianedmurse said:

I find it interesting how you guys have orders on how to administer medications. At our facility the Docs order the medication and its up to nursing to decide whether to push, piggyback, ect. And how fast to administer. There are some exceptions where Docs will order to administer over a period of time (Mag sulfate, Ca gluconate, blood, ect.) though. Honestly props to you for reporting that because I'm not sure I would really consider that an error, maybe I would have written a note in the admin box "given IV push d/t Pt conditon" and left it at that.

We have med admin instructions on our MAR that tell us how it is to be given. How can you have med admin protocols decided by nurse preference? What about meds you are not familiar with? What about a new nurse? I work with residents and they know nothing about administering meds.

OP, every nurse makes mistakes, if they tell you they don't, they are lying. Learn from it and go on ?

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Specializes in BMT.

Oncology nurse perspective: all of our patients have 8mg zofran IV push as the standard PRN order. No, it does not need to be diluted. As others have mentioned before, you push it slow over 2 minutes, and the timing is important because if you push it too fast the patient will vomit. And any patient who asks you to push it slow has probably had it pushed too fast before. If the provider is really considering zofran IVPB they need to consider some stronger antiemetics- ativan or haldol even could work if zofran/compazine/reglan fail.

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