Patient Died from Med Allergy

txredheadnurse, BSN, RN · Oct 7, 2008

I don't have much to add except to echo others postings....it could happen to any of us at any time. It is every nurses worst nightmare but as has been posted also it does not rest soley on your shoulders. To paraphase a saying it takes a village to make a med error of this magnitude.

Hugs, know everyone of us on this bb feel for you, feel your pain and are sending you comforting thoughts and well wishes.

Blee O'Myacin, BSN, RN · Oct 7, 2008

I just found this site and had to post. Ive had the worst day today. One of my biggest nightmares has come true! I killed a patient! Obviously, it was an accident but that is of little comfort to me right now. I've sat here and cried for hours -- I had to leave work early. ...Administered a medication they were allergic to it. It was in their file, but I was told to give it and I didn't double check. Clearly, more than myself is involved in this. I'm so worried -- I may lose my license. I'm utterly devastasted this happened. I think this is my last day of nursing... I can't fathom going back as just started 10 months ago. Just had to vent guys.

The OP states that she was "told to give it" - I wonder if it was despite a stated allergy - ie, the doc didn't believe it was a true allergy?? So my question, if I were a risk management type would be if the physician was aware of the allergy and wrote anyway - and who "told" the OP to give the med? Sounds like this is the kind of sentinel event that really needs to be researched and I hope the OP doesn't take all the blame out of guilt.

I hope the OP comes back and sees the support too. We've all made med errors. And if you haven't yet (students reading this...), you will and it feels awful.

Blee

lunden · Oct 7, 2008

but what about the person who told you to give it. was it a Doc, charge nurse? is it policy to always check their charts, or do the pt's have a wrist band? it seems to me that when someone is allergic to a med, it should be highlighted or in big bold black letters. praying for you and the victim's family.

pagandeva2000, LPN · Oct 7, 2008

I had a situation where I had serious questions about a medication-Azactam (not sure if it is spelled correctly), an antibiotic. I never heard of the med before, so, I looked it up and saw that it shouldn't be administered to anyone who had allergies to penicillin. Took it to the RN, who stated that the patient had already been taking it for 3 days. I was still uncomfortable and was about to call the pharmacy, but decided to speak to the patient first. At that time, I was looking for a peripheral line to hang other drugs and discovered that the patient had a central line, therefore, it was out of my scope of practice to hang any IV medications for this person at all. I was SO uncomfortable with the prospect of having to argue and possibly refusing to administer a medication due to peer pressure. At that moment, it was taken out of my hands, but it did make me stronger the next time to be able to at least gather my resources to speak on why I won't. Scary stuff.

uscstu4lfe · Oct 7, 2008

Well, not only are you to blame, but the doctor that prescribed it is to blame, and the pharmacist that did not catch the error is to blame as well. This is very tragic.

jellybean_1 · Oct 7, 2008

wow I feel so sorry it happened....you are in my prayers.....wish you the best...

cherrybreeze, ADN, RN · Oct 7, 2008

My heart just broke for you. That's the first thing I want to say.

Secondly, please don't take all of the blame for this yourself. Everyone has made a mistake before. Anyone here could do the same thing, as much as we may think to ourselves that it would never happen. I can understand your fear about ever practicing again, but please don't give up hope. Let some time pass, get some counseling, lean on your loved ones. This was a mistake, but YOU are not.

***

On a bit of a side note...in my state, they are changing the allergy bands to be universal throughout the state. They are changing in my facility from yellow to red. You no longer write the allergies ON them, they just say "allergy"...and you are supposed to refer back to the chart for what it is they are allergic to. This practice to me is SCARY, and increases the risk for error. :down:

Tweety, BSN, RN · Oct 7, 2008

It happen to any one of us at any time. I'm sorry this has happened.

Melinurse · Oct 7, 2008

My heart goes out to you. I can only imagine how incredibly difficult this is for you. I'm sitting here reading these posts and have tears in my eyes. I only wish you the best as you go through this difficult time. I hope it makes it easier for you to bear, knowing that there are others here who understand and care. Like others have said though, please talk to someone, whether a close friend, pastor, counselor, etc. I wish you only the best.

withasmilelpn · Oct 7, 2008

I am so sorry, how horrible. Sending you prayers!

loricatus · Oct 7, 2008

Please stop thinking that YOU KILLED the patient. Yes, that poor patient did die and you might have contributed to his/her death; but, it wasn't your INTENT to see that patient expire. It was a serous mistake and probable poor judgement; yet, you are new at nursing and should have had some guidance.

You said that you were told to give the med after doing your job and questioning it. What you haven't learned yet is that you have the right to refuse to give something that you believe will harm the patient. I hope that you did document that you were told to administer the medication after questioning it. If not, go back and put an addendum, since it is better than nothing, at this point. Also, if you have malpractice insurance, call the insurance company now.

Please consider deleting this whole thread because allnurses conversations can be found easily with any search engine-your hospital can turn on you with a statment of guilt like you have made here & blame it all on you, rather than whoever's fault it truly is.

Ms.RN · Oct 8, 2008

you said that you were told to give the med after doing your job and questioning it. what you haven't learned yet is that you have the right to refuse to give something that you believe will harm the patient.

i had few incidences where i called physician about patient being allergic to medications, for example, patient is allergic to codeine but physician prescribes vicodin, or patient is allergic to aspirin products but physician prescribes medications that has allergy products etc. when i notify doctor, doctor still says we can still administer that medication. and some doctors do prescribe antibiotics that patient is allergic to. can nurses still refuse to give that medication?

i have patients on lot of weird allergies like mints, coffee, and medications that are listed as allergies yet patient is taking that medication. how do i know if patient is truely allergic to it????