PPD Wrong dose

[Dadam89]

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.

[heron, ASN, RN]

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.

[Farawyn]

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

Not necessarily.

[KelRN215, BSN, RN]

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?

[Dadam89]

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

[jadelpn, LPN, EMT-B]

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.

[Farawyn]

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]

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.

[Farawyn]

I mean WHEAL! *facepalm*

[xoemmylouox, ASN, RN]

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

Well that explains why you count your syringes. I doubt anything would happen. If you are super concerned I would talk to your manager. I would also suggest the idea that your documentation include lot numbers, amount of medication given, etc.