Sentinel event

[Jordym919]

Hello I am a nursing student in my last semester of nursing school and will be graduating this upcoming May, I have worked in ICU as an aide for the past three years throughout school. A few months ago our ER had a sentinel event from a med error with a child involved, and since then the hospital has made multiple policy changes with medication administration and pharmacy procedures etc. and still we have had some pretty serious medication errors, not sentinel, but still. I am looking for any advice as a new graduate to avoid theses types of errors, in school you are taught to follow your medication rights religiously but are there any other words of advice for a new grad because medication administration is scary as a new grad and after personal experiences in my own hospital workplace. Thanks!

[Julius Seizure]

A bag of potassium that was meant for an adult patient was given to a child less than a year old instead of the ordered NS... it resulted in cardiac arrest.

Yikes [emoji15]

[SHGR, MSN, RN, CNS]

I have a question about these--

Don't blindly trust the pharmacy label. We got a patent transfer recently a nurse had hung some Pitocin on a laboring patient. At least that's what the label said...it was NOT. Patient ended up in ICU..it was some entirely different medication.

If pharmacy mixed and labeled the bag, how would the nurse know if this was incorrect?

NEVER speed up any drip to prime the IV tubing unless the pump has a special prime function. I learned early to never do this but my coworker did not. She sped up a Lidocaine drip from 20 cc per hour to 220 cc per hr to prime the tubing after an IV restart. She forget to turn it back and the patient started seizing once they got toxic levels.

I guess I don't understand this either- why would you prime into the patient rather than a wastebasket? I am picturing forcefully priming a tubing full of air into the patient.

[Julius Seizure]

I guess I don't understand this either- why would you prime into the patient rather than a wastebasket? I am picturing forcefully priming a tubing full of air into the patient.

She means running it at 200ml/hr *not hooked to the patient*, and then hooking it up to the patient but forgetting to re-set the rate to the ordered 20ml/hr.

[TriciaJ, RN]

The busier you are, the more you will want to speed things up and cut corners. Do not ever do this. My rule: the more pressured I feel, the more I slow down and double-check things when I am administering meds. Always look at each med label 3 times: 1. When you are about to pick it up for the first time 2. After you pick it up to make sure you have what you think you have 3. Last thing before it goes into the patient.

You got good advice about stopping to double check whenever a patient questions his meds. Many med errors are systems errors; this means more than one person contributed to the ultimate error. Never be afraid to complete an incident report. These identify systems errors and help hospitals update policies appropriately. Kudos to you for planning ahead.

[Jordym919]

I really like your advice about the more pressure you feel the more you slow down! I feel like stressful and hurried times are when most errors happen, so thank you so much!

[Julius Seizure]

I have a question about these--

If pharmacy mixed and labeled the bag, how would the nurse know if this was incorrect?

Quite often meds will come in pre-filled bags/syringes (rather than being mixed in our own pharmacy). So potentially pharmacy could grab a manufacturer's bag of dopamine and slap a patient label on it that said nicardipine. Oops. Always check the pharmacy label BUT always check whats on the actual syringe or bag too.

Another example would be IVF with additives. Pharmacy may have meant to send you whats on the label - D5 1/2NS + 40 KCL, but the accidentally grabbed a D5NS bag?

[LeChien, BSN, RN]

A bag of potassium that was meant for an adult patient was given to a child less than a year old instead of the ordered NS... it resulted in cardiac arrest.

Omg!!!

[EaglesWings21, ASN, RN]

I have made a few silly but preventable errors in my first year as a nurse. There are so many distractions and things on my mind, it's a wonder I haven't made more. My advise is always stay focused. If you are unfamiliar with something look it up. Try not to get too comfortable with day to day tasks.