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PPD Wrong dose

Dadam89 Dadam89 (New) New

So I should start off by saying I am not 100% sure that the wrong dose was administered but I'm a brand new nurse and was working with an LPN today who said she could go give the person a PPD test. She said she'd done it hundreds of times working at her old facility, I probably should have watched her do it but didn't and only thought something was wrong when the sharps didn't add up. There was a intramuscular syringe missing and all the TB ones were there. It's also very possible that the count was just off (sometimes the DON takes one syringe to make sure we're actually counting) I went and checked out the person's arm and the wheel looked twice as big as it normally dose.

-Again since I'm not 100% sure a wrong dose was administered (and possibly wrong administration) I was just wondering if giving a double dose of PPD in one injection had any serious side effects. Haven't found any articles going either way so I'd appreciate any feedback so I can hopefully get some sleep tonight.

I was not certain that the person who administered my pneumonia vaccine had given me anything, since she later stated she had just administered some empty flu injections. We were at a public immunization clinic. My doctor told me to wait one year then get revaccinated. The company providing the service refused to refund my money or otherwise remedy the situation. Is there any way you can check the vials, to try to determine how much was used that day?

There are several vials open so unfortunately not. The paperwork also didn't require the lot number or anything so I have no idea which vial was used. This was administered around 0400 today and at 0630 when I saw it the person had no complaints and was not in any apparent distress. I didn't even put two and two together until I realized the count was off and remembered the wheel had seemed a little large. The syringe that was missing was a 3cc and thinking back on the size of the wheel I can't imagine it was more than 0.5ml but even so the right dose is 0.1ml.

AnnieOaklyRN, BSN, RN, EMT-P

Specializes in ED, Pedi Vasc access, Paramedic serving 6 towns.

Why don't you just ask the nurse involved?!!!

Hprn

OCNRN63, RN

Specializes in Oncology; medical specialty website.

​It's a "weal," not a "wheel."

HappyWife77, BSN, RN

Specializes in Gerontology RN-BC and FNP MSN student.

That is crazy.....using an IM to give a sub dermal injection? Exactly how big was the weal?

I would ask her for sure....then have her demonstrate what she gave to make sure...

Now I understand why my state requires certification to administer TB injections.

Are the needles you use separate from the syringes? If she did use a 3cc syringe, is it possible she could still have attached an appropriately sized needle for an intradermal injection? It is not ideal, but you can measure 0.1cc w/ a 3cc syringe.

As others have said, I would suggest talking to her. That would answer all of your concerns rather quickly. If you can't wait until you see her again, maybe you can give her a call since you suggested you might lose sleep over it tonight.

You guys count your needles/syringes?

PPD is kinda harmless unless the patient has TB, received BCG, or is allergic to it. If "double the dose" is given it won't hurt anyone who isn't reactive- if they do have TB, the induration will be that much worse, probably.

Then again...an entire IM syringe full of the stuff? Omg. The poor patient.

Edited by Farawyn
To enhance my ellipses....

When I place a PPD, the tip of the needle is just barely under the skin's surface, so that .1ml makes the appropriate wheal....and it's pretty visibly there. I'm trying to picture how someone gives significantly MORE than that (like 10x if someone drew up 1.0 instead of 0.1) and doesn't create a PILLOW on someone's forearm?

Wheal, good to know. Thank you all for your responses, I should probably just call her and discuss my concerns (she was gone by the time we did count and I put two and two together). It's not possible to take off any of our needles (they're the cheap kind). It definitely wasn't a pillow but more like a dime which still seems to big for me. Again it probably wouldn't have even come to my attention had the count not been off and the only thing I'm really worried about is some kind of severe reaction for an extra dose. It seems like at this point though since no one has mentioned any kind of death related outcome from extra PPD then I'll just call her, get her side of the story and tell the nurses this week to keep an eye on the person. Thanks again!

cayenne06, MSN, CNM

Specializes in Reproductive & Public Health.

Shouldn't she have documented this in the patient's MAR, with the dose/route/location?

heron, ASN, RN

Specializes in Hospice.

Just speculating here, but I suspect that the most that can happen to the patient would be a more severe local positive reaction. While unlikely to be life threatening, local over-reactions can result in ulceration and necrosis requiring treatment that might involve its own adverse side effects, ie steroids. This is why we don't give ppds to people with previous positive reactions and BCG vaccination.

As for how much did she give and how, I agree - ask her.

Shouldn't she have documented this in the patient's MAR, with the dose/route/location?

Not necessarily.

KelRN215, BSN, RN

Specializes in Pedi.

Ask the nurse what she gave. I have never heard of counting syringes/needles. Do you have a big problem with people stealing these things to give to their junkie Grandpa or something?

Without breaking too much confidentiality, this is a jail not a hospital.

As a complete aside, here is what seems really, really "off" to me. Ya'll count syringes, however, you do not document the lot number and expiration date on any PPD you give?

That is a huge process issue.

Further, it is difficult to determine if the wheal is in fact larger due to a positive PPD or using a larger amount of the solution. Which now, I would think that further testing would need to be done--as some nurses would read that as a positive.

The bigger question here, however, is that your facility doesn't require any supporting documentation on immunizations/PPD's and the like. And if there's multiple vials open, one could easily expire and no one would know the difference. And if your facility is audited, I am not sure that they would overlook no supporting documentation.

I would ask the LPN in question. And if you have your doubts, it is medication error. That would require re-education. And a policy. The MD should check the wheal, and proceed with whatever policy is in place (providing there is one) regarding positive PPDs.

As a complete aside, here is what seems really, really "off" to me. Ya'll count syringes, however, you do not document the lot number and expiration date on any PPD you give?

That is a huge process issue.

Further, it is difficult to determine if the wheal is in fact larger due to a positive PPD or using a larger amount of the solution. Which now, I would think that further testing would need to be done--as some nurses would read that as a positive.

The bigger question here, however, is that your facility doesn't require any supporting documentation on immunizations/PPD's and the like. And if there's multiple vials open, one could easily expire and no one would know the difference. And if your facility is audited, I am not sure that they would overlook no supporting documentation.

I would ask the LPN in question. And if you have your doubts, it is medication error. That would require re-education. And a policy. The MD should check the wheal, and proceed with whatever policy is in place (providing there is one) regarding positive PPDs.

The positive PPD wouldn't show right away. The big heal would be evident immediately, and if negative, I would assume it would be absorbed.

klone, MSN, RN

Specializes in Women's Health/OB Leadership.

Yeah, an extra large wheal will not still be there 72 hours later - it's still going to be absorbed by the body, but maybe just a few hours more than it normally would.

I mean WHEAL! *facepalm*

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