I am a (starting) 3rd Quarter LPN student, and I work as a CMA in an Urgent Care clinic. In my facility, LPNs and CMAs are interchangeable: we have the same duties and responsibilities, all under the auspices of the MD inhouse. As is my basic nature, I am VERY careful when it comes to med administration - I'm the type that will do 3 or 4 verifications on a med before I pass it. If this had been a "serious" med, I don't think I would have made the mistake; however, because it was an OTC, I got in a hurrry and got careless; and it came back to bite me on the assets!
Yesterday, I had a family come in (3 little ones and both parents) all pos for strep A. Initially, only two were my pts - the older two children. After screening, I discovered the middle child had a temp, while the eldest was afebrile. Per facility protocol, I administered (correctly) the correct dose by weight of APAP liquid to that child. As I was finishing, Mom asked if I thought the youngest (2 y/o) had a fever; upon checking axillary temp and seeing 102.2, I said "Yup, she's got it too. Let me get her some tylenol as well." So.... I went to the med cabinet and poured the correct dose for her weight, and went back in and administered it. No problem. Later, when the MD made it into the room, he checked all three of the kids, then came out and had me strep-swab the two parents as well. EOS, the whole family was treated for strep, and off they went.
A short time later, the other CMA on duty came up to me and asked "Are you SURE that was APAP you gave that last time?" Of course I was sure! Until she led me to the cabinet and I saw that the children's APAP suspention bottle that I used on the first kid's dose was pushed BEHIND the bottle of children's benedryl! I honestly COULD NOT remember whether I had given the little one APAP or diphenhydramine! Both bottles LOOK the same, as does the med within! Oh.... SHIZZLE! A panicked check of the chart and a quick calculater session revealed that I administered 8.25mg of diphenhydramine to a 28lb 2 y/o. Not enough to hurt her, THANK GOD!!!!
The LPN on duty told me I had to tell the MD, which I did. He told me I needed to advise the pts parents, have them recheck the temp, and if still elevated (which it would be) to administer the correct dosage of APAP to the little one. Done, and the parents understood - again thank God. The MD also said that if this was the only med error I ever made in my career, I should be greatful that is was one without serious consequences. Boy howdy, am I!
The moral of the story: Always verify the med pulled EVERY TIME! Even if you just gave the same med two minutes before, even if you THINK you know what you are getting. The "5 Rights" are there for a reason. I am sooo greatful that I learned this lesson before I seriously hurt someone.
Good lesson but where are you that you still have stock medication? We have a pixis system where every thing is single dosing pretty much. Medications like Tylenol although it are not single dose it is in a single drawer so you cannot accidently give benedryl. Benedryl is however single dose in our facility.
I work for an Urgent Care clinic. Think "Doc-in-the-box plus junior ER".
We are building a new facility next door - it will have pyxis and single-dose everything.
On my own initiative, I have moved the tylenol to the opposite side of the cabinet from the benedryl.
But what if teh child had been allergic to benadryl?
Many people are allergic to meds that aren't "serious", to OTC meds, etc.
point being, all meds should be verified carefully, not even OTC meds should be treated carelessly.
glad all turned out well.
Agreed, and this is what continues to bother me about the whole situation. However, as a usually extra-careful practitioner, I was constantly back in the room to check on my pts. As a former EMT, I think I'd have picked up on an anaphylactic reaction really quickly.
This was a completely avoidable error - IF I had done what I knew I should have done and READ the stinking bottle rather than just "grab" the med and go.
Good lesson but where are you that you still have stock medication? We have a pixis system where every thing is single dosing pretty much. Medications like Tylenol although it are not single dose it is in a single drawer so you cannot accidently give benedryl. Benedryl is however single dose in our facility.
I work in an ER and we have stock meds: Tylenol, Motrin, Benadryl, Dimetapp, Septra, Tussin and Tussin DM..........
Tylenol was administered at my facility by a nurse to a patient with liver problems.
This person almost died. He had a rough go of recuperating from his injuries.
My mother has end stage liver disease. I once accompanied her to her appointment with her physician's assistant. I was shocked to learn that the PA recommended that she take Tylenol instead of any NSAIDS. Of course in small quantities and never continually. It still shocked me, though.
clee1
832 Posts
I work for an Urgent Care clinic. Think "Doc-in-the-box plus junior ER".
We are building a new facility next door - it will have pyxis and single-dose everything.
On my own initiative, I have moved the tylenol to the opposite side of the cabinet from the benedryl.