Was this a med error?

[aquamarineyesRN07]

I am in my first year as an RN and have been off orientation for three months. I feel pretty confident in my skills and don't usually feel hesitant to ask questions from my coworkers; I work with a great staff. Still, I feel very new and unsure of myself at times.

Last week I had a patient two nights in a row. The first night she was getting 2mg Dilaudid IV every 4 hours for pain. When it came time to give her a dose my second night with her, I drew up a full 2mg and diluted it as usual in my 10ml saline. However, the orders had been changed to 1mg every 3 hours. This was also my unit's first week going "live" on our electronic MARs, and while I should have been more cognizant of the 5 rights in the first place, I felt a little frustrated at not having that "one last check" right there on the paper MAR in my hand like we had before. I was already in the patient's room when I brought up her MAR on the computer there to do my last checks when I realized my mistake. I ended up pushing only 5ml of the syringe.

Because it was diluted and dispersed in the saline, did this still equal 1mg? Should I have gone out and redrawn the Dilaudid? Obviously my gut is telling me yes, that would ensure a full 1mg. Was this a major med error I should have addressed?

[blondy2061h, MSN, RN]

I wouldn't have had a problem doing what you did, as long as you shook the syringe gently to mix it. It's really no different than mixing a med in a vial and drawing up half the vial if you need half the dose that's in the vial.

[annreese]

I probably would have redrawn it and made sure to document it. I suppose if you mixed it adequately it shouldn't be a problem. Also what did you do with the remaining 5? Make sure you document that too. Here, the orders are closely checked against the pyxis and if they don't add up we get the riot act.

[nurse_mo1986]

no, this doesn't constitute a med error. In my unit where we frequently give ativan ivp for seizures, od pt's, it's common to mix ativan 2 mg in 10 ml ns, then give 1mg/5 ml.

[jetsetter]

I don't believe this is an error. As long as it was mixed the pt got 1mg.

[Ayrman]

You'd have to split the hairs very finely to be able to say that you "could" have given more than the 1 mg ordered. The other responses are correct. You mixed the med in saline and gave half which by all rights should have figured out to a 1 mg dose.

Glad to see I'm not the only one who dilutes. At a concentration of 2 mg in 1 ml solution (here any way) it's extremely difficult to make a slow controlled push when your syringe plunger only travels a fraction of an inch (3 ml syringe is the smallest we have without a pre-attached needle, and of course we use needleless access ports). I dilute all my controlled meds for that reason, regardless of the concentration, and much to the dismay of many a tweeker I refuse to "slam" the push just so they can get a quick fix. Slow and safe or not at all.

Ayrman

[Babs0512]

I wouldn't constitute this as a med error. You drew up 2mg, in 8cc NS, that is 1mg/5ml. You gave 5ml, no problems - relax, you did fine.

Blessings

[diane227, LPN, RN]

This was not a med error. You had 2 mg per 10 ml and you only gave 5 ml then you gave the correct dose.

[TAB_RN]

Actually, you actually gave less than the ordered dose. If you drew up 2mg/1ml... then added 10 ml ns, and then gave 5ml - that is slightly below the 1mg order. It should have been 5.5ml :)

No worries....