Patient died from 8GMs of Dilantin - page 2

From the Sun-Sentinel: The highlights: -ER nurse, with 9 years experience, is caring for a 44 y.o. F patient, c/o seizure with hx of same. The patient ran out of Klonopin and has no health... Read More

  1. by   GardenDove
    Quote from Angie O'Plasty, RN
    What's weird to me is that after nine years of nursing, she made a mistake like that? Dilantin IV is fairly common down here.
    That's what I was thinking.
  2. by   SmilingBluEyes
    The two threads on same subject merged. ENJOY!
  3. by   nursehellokitty04
    hey i all i have to say to that is DUH!! how in the world can you make an error like that? or not question the doctor about it? the doctor shouldnt have been fired. the nurse however thats something else.
  4. by   santhony44
    Quote from GardenDove
    The article stated that the dismissal of the doc was part of the deal with the husband of the dead woman.
    In other words, the doc's being hung out to dry to keep the family from suing the hospital? I suspect he'll win his wrongful termination suit. It doesn't sound as if the error was his.

    I can't imagine what the nurse was thinking not to have noticed that there was something odd about the dose. Dilantin is still a pretty common drug, surely the nurse had given it before!

    What a thing to have to live with the rest of your life.
  5. by   nrsang97
    I cannot imagine even drawing up that much dilantin without bells going off in my head. 8 GRAMS come on. I feel for the pt husband and family. I think the doc did nothing wrong in this case.
  6. by   Nursonegreat
    she clearly wasnt familiar with IV dilantin. first rule if u r not familiar with a drug is to look it up. i know everyone is so busy, but it takes a few seconds to look it up. i have given drugs IV in emergency situations (ie codes) that i was not familiar (and therefore didnt have time to look up) with but was being told "give it!" so i would repeat the dose out loud and ask how fast/slow etc. but to pull up 32 vials, seems like she couldve had an extra 30 seconds to look up the drug. sad. she'll carry that around forever and the family will too.
  7. by   fultzymom
    Quote from Tweety
    The 800 mg the MD ordered is not a huge dose for a seizing patient. Loading doses are often up to 1000 mg. I wouldn't have questioned the MD or batted an eye at this ordered dose.

    8000 mg as we are reading is a lethal dose. I can't fathom drawing up that much Dilantin. I hate to judge, the nurse must be devastated.

    There must be more to the story that we are reading about the MD because calling a family on a death in the ER doesn't seem unusual. Unless there is a specific written policy that it's the chaplin's job, or some other policy he/she broke.

    I meant the 8000mg the nurse gave. What I meant was I can not believe that she did not question giving 8000mg of Dilantin. I could not imagine not questioning an order for 8000 mg of anything.
  8. by   cheshirecat
    I know of a nurse who misread a prescription and gave 50mg of morphine instead of 5mg IM. She checked the drug with another RN (all controlled drugs must be checked by 2 people over here) and gave it. She had to open 5 vials to give this dosage. Her excuse - she had gotten mixed up with pethidene. Patient survived but it does worry you.
  9. by   AnnieOaklyRN
    This is a very sad situation for both the family of the patient and the nurse and her family.

    We all make mistakes, unfortunatly this one cost someone their life. I am not minimizing her error as I feel, like many others do that red flags should have been going up many times over.

    I think this nurse is going to need a lot of prayers and support because she is going to be guilt ridden probably for the rest of her life.

  10. by   squeakykitty
    Quote from CraigBSN02
    -The nurse had to get THIRTY-TWO vials of Dilantin from 3 seperate Pyxis units.

    -The nurse had to start a second IV to administer that much Dilantin.
    All of this would have also taken some time, time enough to think about what she's doing. And the nurse didn't question 32 vials and having to go to 3 pyxis units? :smackingf I learned that if you have to use more than three, to double check.
  11. by   UM Review RN
    Quote from squeakynurse
    All of this would have also taken some time, time enough to think about what she's doing. And the nurse didn't question 32 vials and having to go to 3 pyxis units? :smackingf I learned that if you have to use more than three, to double check.
    I'm so paranoid that if I have any questions, or if I don't use a medication enough to feel comfortable with it, I'm on the phone to Pharmacy verifying stuff.
  12. by   kitty=^..^=cat
    Considering the magnitude of this error, $200,000 seems like a really low settlement amount.
  13. by   dijaqrn
    There has to be more to this..........
    No one noticed this nurse drawing up 32 vials??????????????