Severe Reaction to PPD testing

[madwife2002, BSN, RN]

It is time for PPD testing where I work and one of the ACT's had an RN do her test we dont have an occupational health department so the Rn's do the testing. About 10mins later she came up to me and asked me to look at it as it was burning and was already swollen. A few hours went by and her arm was swollen to the size of an egg. I asked her if she had been exposed to tb as she was having a positive reaction. It continued to detiorate and now was the size of 2 eggs, bruised, discolored and her hand was begining to feel numb. It was decided she need to go to the ER for evaluation-she asked the RN for the vial as it was multi dose and she needed the lot number.

Then it was discovered that she had actually recieved pneumonia vaccine and not the PPD test plus it was 6 months since the vial had been initially used for the first time.

She recieved emergency treatment at the ER and appears to be recovering slowly.

Have you ever heard of such an error and if so what was the outcome??

[netglow, ASN, RN]

Who knows but your description sounds like a necrosis, a necrotizing fasciitis to septic thing. This worries me IDK why I am so anxious (sorry). I am sure she is watched very, very closely and hopefully for weeks to come.

[lpnstudentin2010, LPN]

wow that is crazy.

[realnursealso/LPN, LPN]

No I've never heard of someone getting a PPD test with pneumonia vaccine. Outcome? I'd say medication error.

[southern rn]

wow. If someone gave me a transdermal skin test with outdated pneumonia vax I would be beyond pizzed. Where in the world did the RN get the vial (it was opened 6 months ago)! and why didn't she actually read the label on what she was getting out!Hope this person is OK.

[gr8rnpjt, RN]

This is an error that should never have happened. I hope the patient has a good outcome.

[aura_of_laura]

... and this is why employee health nurses are handy to have around!

A vial that old shouldn't even be in the fridge. Also, does your facility give employees pneumovax? I know that my hospital doesn't offer that one - if she received old, opened vaccine from your patients, that's even worse!

I would think that this should definitely spur some policy and practice changes at your work. I hope the affected nurse is feeling better!

[PedsAtHeart, LPN]

I do all employee PPD testing here at my clinic. I have a big fridge with PPD along with every other kind of immunizations since I am also the immunization nurse. BUT this is an error that NEVER should have been made! I recently went to training at the state health department and they mentioned that sometimes adult Td vaccine gets mistaken for PPD since their labels are kind of alike. But what are we taught in nursing school over and over and over again? When giving any injecable medication you check the label AT LEAST 3 times. When you get it out, while you are drawing it up, and then when you are finished drawing it up... Seems to me if this nurse had done that this mistake wouldnt have happened. I agree with the other commenter, I would be VERY upset if someone did that to me. I hope that nurse is reprimanded and is made sure never to make this mistake again.

[kathy313]

That's horrible. I would have raised holy **** with that nurse. What happened to identifying the med, the dose, the patient??? Technically not a patient...but the same rules apply. Just crazy.

[diane227, LPN, RN]

My husband has a severe allergy to the PPD. He develops severe cellulitis up his entire arm. But you cannot imagine how many times and how much trouble it is to try to explain it and get people to understand that he cannot get a standard TB skin test.