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Discussion

Nitrospray Questioning

Situation - resident with cardiac hx presents with severe chest pain, altered heart rhythm (which may or may not have been chronic) and mild hypertension. Dr gives telephone order - "give him three sprays nitro and if it doesn't help, send him in." Clarification question, "Ok, give him three now and if he doesn't recover send him to hospital?" "Yes." Administered, resident presents with dizziness and tremors, then syncope and dropped O2 sats and mild hypotension, regains consciousness but ++ anxiety and increased pain, EMS engaged.

Felt I should've questioned the order as the dose was excessive, especially for this age group and may have contributed to the need for EMS. Nurse managers stated all was done correctly and that the physician may have more knowledge on the patient that directed the treatment plan. I still think the order was inappropriate and could've been even more disastrous, but the moment was time sensitive and I didn't critically think the order (the drug is rarely given in this setting) until well after administration.

What would you have done?

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    • Experts

    Did you give all three sprays at one time or did you wait 5 minutes in between?

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    • Author

    Three together. I explained that point to the NMs as well and they both agreed that it may have been an appropriate order and I followed it correctly as stated. The typical protocol is one, wait five min, if not resolved give up to two more q5min.

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    Three together. I explained that point as well. The typical protocol is one, wait five min, if not resolved give up to two more q5min.

    Then you should have clarified exactly how the ordering provider wanted the sprays administered. After receiving the following order "give him three sprays nitro and if it doesn't help, send him in," rather than reading back "Ok, give him three now and if he doesn't recover send him to hospital?" you should have asked if he or she wanted the three doses simultaneously, or rather space the doses 5 minutes apart. It's possible that he or she assumed that was how you were going to administer them; rspecially if that is your typical protocol for administration.

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    • Experts

    I agree, I would have clarified how he wanted it administered. I have never given Nitro or heard of it being given as three sprays at one time. And I would not have done it that way. It was not a correct order as stated or carried out regardless of what your nurse managers say. This was a breakdown in communication starting with the physician. Additionally, nitro is contraindicated in RVIs and may result in shock and asystole if given. Without an EKG (and someone who can read them not just rely on the machine interpretation) it would be impossible to rule it out. That is one of the reasons the doses are spread out...to evaluate patient response. My intention is not to bust your chops but this is a med error, however, it is most definitely not all on you. As you have learned, nitro is not a benign medication and it has some gnarly side effects. In the ED we try to get a line in the patient first before administering the nitro because of them. This needs to be addressed with the physician who gave the less than stellar order. I'm sure the entire episode was stressful for you. Your instincts were correct. Have confidence in your knowledge.

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    • Author

    We don't have a set protocol for nitro (due to the side effects) and it is rarely administered, so the rx is specific to the patient and usually a one time only order. Yes, I made an error in clarifying the order and should have specified the frequency. Fortunately there have been no long-term effects on the resident and they returned home with no significant findings. Part of what is troubling me is that I'm fairly sure if this had occured earlier in the shift and not at the end of a 12hr night, I would have been sharp enough to pick up at the time of order that the dose was not within usual parameters. Should have been less reactive and taken more time to review and process the order.

    I posted in part to find out 1) Is there any situation in which this dosage would have been indicated and 2) assuming it was a med error due to poor communication on both our ends and the GP did actually mean to have it spaced out, is there more I should do at this point to report the probable error (given it was reported to both managers and it did not result in injury to the resident) or file it as a learning experience and move on?

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    • Experts
    I posted in part to find out 1) Is there any situation in which this dosage would have been indicated and 2) assuming it was a med error due to poor communication on both our ends and the GP did actually mean to have it spaced out, is there more I should do at this point to report the probable error (given it was reported to both managers and it did not result in injury to the resident) or file it as a learning experience and move on?

    Regarding your questions.

    1. No there is no situation where giving 3 sprays of Nitro at one time is correct. There are no indications for tripling the dose. If anyone ever asks you to do this refuse to carry out the order. It is wrong.

    2. A lack of permanent injury is not a reason to omit filling out a report. The reason behind these reports is to identify and correct process or education issues. You have both here. It is especially important when you are dealing with an urgent/emergent situation and a relatively unfamiliar drug. The GP may not even know how to properly administer it. Your nurse managers are obviously clueless about Nitro and frankly the patient was harmed...just not permanently. There is some serious education that needs to take place regarding telephone orders, communication, the drug itself, managing CP prior to arrival of EMS. And you identified another issue...end of shift exhaustion and how it impacts nursing judgement.

    I think you are asking all the right questions and I hope you don't feel like I'm bashing you because I'm not. In my facility this would qualify as a sentinel event. I'm most disturbed at your managers' lack of concern however I do not for a second think you need to be "punished". Things like this happen all of the time. What will make you an even better nurse is what you learn from it and how you apply it to your nursing practice.

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    • Author

    I understand you are not bashing, you are educating and advising and I appreciate it. I've been in the field for several years and have never (to my knowledge) made an error like this where a patient/resident was jeopardized. I have a meeting with my immediate super this week and will discuss it again, this time in person instead of over the phone.

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    • Experts
    I understand you are not bashing, you are educating and advising and I appreciate it. I've been in the field for several years and have never (to my knowledge) made an error like this where a patient/resident was jeopardized. I have a meeting with my immediate super this week and will discuss it again, this time in person instead of over the phone.

    I'm very relieved you are interpreting my posts as they are intended. I can help you formulate a plan to present to your supervisor if you'd like. In the meantime I think reading up on Nitro would be good especially since your leadership is so appallingly uneducated about it. Somebody needs to be the expert...why not you?! :-)

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    • Experts
    I understand you are not bashing, you are educating and advising and I appreciate it. I've been in the field for several years and have never (to my knowledge) made an error like this where a patient/resident was jeopardized. I have a meeting with my immediate super this week and will discuss it again, this time in person instead of over the phone.
    I have always followed a rule of thumb.....if I am not familiar with a drug I look it up before giving it. Nitro spray is administered like the sublingual sprays. One spray under the tongue x three 5 mins apart IF the B/P remains >90 systolic.

    I think you are doing the right thing by discussing this and coming up with a system solution to prevent this from happening again.

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    Reminds me of an episode of ER I think it was? A med student was assessing a chest pain pt, and he takes a bottle and goes "squirt squirt squirt" under his tongue. The nurse asks "What did you just do?" He said "Nitro x3." The nurse: "All at the same time???" The pt: "I don't feel so good......"

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