Major Med Error

Nurses Medications

Published

Today I gave my pt. 2mg IV Ativan for anticipatory anxiety for a MRI. Her order was for 1mg, I obviously read the order wrong.

Later in the day, she was difficult to arouse, but her VSS. The following RN elected not to give any form of pharmacology reversal (Narcan), and called the SUP.

The pt. was sent to the ICU and now is vented.

I'm so sick thinking of what I may have done to this woman. Can anyone please tell me of my rights as a RN? I spoke to my SUP and admitted "I read the order wrong". Any advice would be greatly appreciated. I've a stellar Nursing record, and I can't even think of the worse case scenario.

Thank you.

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Specializes in Oncology.

Everyone makes mistakes. A good hospital will not view med errors punitively. For future reference, narcan won't reverse Ativan. Flumazenil is the reversal agent for benzodiazepines.

2mg of Ativan should not cause a normal person to end up so sedated they end up intubated and vented several hours later. IV Ativan is only active about 6 hours. I highly suspect something else was going on that caused that. IV Ativan peaks very quickly. If she could maintain her airway and respirations shortly after it was given, it would get better the further from the dose- not worse.

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I was going to say the same thing. You did not cause her to be on the vent. However, what a learning experience this was for you. Now, beat yourself up only one more minute THEN STOP!! I have been there and I have been a nurse for 30 years.

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Thank you for the response and Pharm. education! ;)

I'm pretty good will my half-lives of meds., and was trying to be diplomatic. The RN who sent the pt. to the ICU has a hx. of creating drama. However, I agree that would not cause her to be on a vent, and this may be the opportunity for the MD to find an underlying cause.

Thanks again.

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Thank you @HospitalsSafety, I certainly will. I really needed your sense of humor tonight also. It's nice to find such inspiring Mentors here. I've been a RN just over a year, and love that I found this forum. Thank you so much!!

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Specializes in Pedi.

2 mg of ativan is not that much for an adult. We give that dose to 20 kg kids all the time.

P.S. Narcan would have done nothing to reverse the effects of ativan. Narcan is the reversal agent for narcotics. If you want to reverse the effects of benzos, you need to administer flumazenil. I have never once seen this given.

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I wouldn't consider that a *major* medication error, but it's a pretty bad one. Most people can handle 2mg lorazepam IV without ending up on a vent. How old was this person?

P.S. Narcan is for opiate overdose. It will do nothing to reverse benzodiazepines. flumazenil is the antidote for those.

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There is something going on with this patient. That has little to do with the Ativan. Especially several hours later. If her VSS, WHY is she now on a vent? Seriously? Perhaps an adverse reaction?

If you have a vial of Ativan, and it is 2mg in said vial, then the other mg needs to be wasted. So in the future, remember to bring someone in with you to draw up and waste.

2mg, at least in my neck of the woods, is not something we normally give--unless someone is in active withdrawal from ETOH. So question that if in the future you are giving it for anticipatory anxiety. And if you are scanning meds....it didn't pop up that the dose was wrong?

And I am not sure that if in fact the nurse in question felt it was a reaction to the dose of Ativan, why she did not advocate for flumazenil. If this is due to an addiction to drama, then that is a heck of lot more scary than 2mg of Ativan.

Call your carrier for advice. If you are union, get your delegate involved so they are in the loop. There is something about this whole thing that is not adding up.

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I agree. Thank you also for the Pharm education.

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The reason I tittle it major, it because I might get fired from it. I'm new to the process of med. errors, and the intention of this post was more about my rights as a RN.

The pt. was 75 y-o, which I've given that amount to pt.'s that age several times, I believe there is some underlying cause.

Before my hospital calls me, I was hoping to gather some information regarding anyone who's made a med error and/or dealt with admin.

Thank you for your time.

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I completely agree with you. Yes, it's my nursing judgement to give the med before the procedure, and yes, it did probably pop up on the scanner. I probably dismissed it, I don't remember. The thing is, at times we are so short staffed there is no other RN to waste with. Welcome to my biggest fear!

Now,that's what scares me also that she did not advocate for flumazenil, coming from a RN who gave a complete bottle of insulin thinking it was protonix. I digress.

Thank you so much for the tip on calling carrier for advice. I'm really naive when it comes to admin things.

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Specializes in Acute Care Pediatrics.

There is no way 2mg of ativan is going to take down and vent an adult with no comorbidities. Like a previous poster said, I have given that dose to youngsters! Not that you didn't make a mistake, but I do not think that this is the mistake that ended her up downstairs on a vent.

And I hate that every time I see a nurse post about a med error that they followed up on the appropriate way - that they are worried about losing their job. Isn't it supposed to be a non punitive system for reporting med errors!? GRRRR!!!!

I really think you are ok, OP. I'm sorry that this all went down and caused you to doubt yourself, though. You know, we all make mistakes. :( We are human.

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