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The Wrong Dose - A True Story of Medication Error

Safety Article   (31,859 Views | 34 Replies | 1,303 Words)

SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

12 Followers; 54 Articles; 17,874 Profile Views; 340 Posts

Safety Nurse sat down with Margo, a fantastic oncology nurse, who talked about the night she gave a patient too much insulin, and he coded. He lived, and Margo is still at the same job. The hospital where she worked supported her and included her in a Root Cause Analysis of the event. Margo is now a well-respected nurse leader at her place of work. In the interview, she opened up about how the error went down, and we talked about the inevitability of error. You are reading page 3 of The Wrong Dose - A True Story of Medication Error. If you want to start from the beginning Go to First Page.

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It sounds like you had a very different experience. Unfortunately, from what I have seen as a nursing instructor at many different schools of nursing the practice in many schools of nursing is to be task oriented. There are as many different ways to teach nursing as there are ways to be a nurse. I am so glad you had a good experience. Please let us know where you went! I would love to have a place to recommend to folks.

I went to a hospital-based diploma school that is no longer in operation. I got an excellent education in nursing, and it was certainly not "task oriented." The ADN and BSN programs in which I have taught in the past were also not "task oriented" to the exclusion of higher level knowledge and critical thinking.

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14 Posts; 681 Profile Views

When I was a new nurse, my very first day on the floor nonetheless, I had a patient who had a colon resection having severe pain that was uncontrolled with his current regimen.

I asked the resident for a breakthrough dose of IV dilaudid and he ordered it- a whole 25mL/25mg PCA syringe as a one time dose.

It was the resident's first day as well, but that is no excuse. He was able to order it without PCA settings (bolus dose, lockout) literally as just the whole 25mg of IV dilaudid as a one time dose-- and pharmacy verified it. I only realized the error when I went to pull this medication and realized the size of the syringe, which also read: FOR PCA USE ONLY.

Thankfully, I did not give this medication and the error was corrected. What a reminder that as RNs we truly ARE the LAST line of defense for the patient when it comes to med errors. You are not alone. :)

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810 Posts; 11,855 Profile Views

You're very lucky, but I think the way your error was handled is the correct way.

Sadly, many nurses are severely disciplined or even terminated for even minor medication errors. This punitive mentality can only lead to cover-ups and harm to patients due to non-reporting.

Thank you for being an advocate... but there's a long way to go for the profession as a whole.

Edited by DeLana_RN

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Orca has 25 years experience as a ASN, RN and specializes in Corrections, psychiatry, rehab, LTC.

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Thank you for the article. Medication errors can happen at anytime whether your new nurse or experienced nurse.

I just started traveling as a nurse and I had a charge nurse said to me that I asked too many question. I told her I'm going to be a safe nurse so if I don't know or if I'm not sure I ask questions. I would much rather somebody think I don't know that much then to make an error.

Great article!

I had much rather have a nurse ask questions about something that he or she is unsure about than to blindly charge ahead and do the wrong thing. I never mind questions.

Margo was indeed fortunate to work for an employer who is so supportive, and so cognizant of the fact that many errors are facilitated by the system in which they occur. Many employers would have just terminated her, perhaps reported her to the state board of nursing, and left her emotional and professional scars to become someone else's problem.

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LilPeanut has 8 years experience as a MSN, RN, NP and specializes in NICU/Neonatal transport.

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I had an RX near miss - we had an order set for extravasation meds, and they had switched the order they were in before.  I was discussing another patient whose condition was deteriorating when an RN notified me that an IV with TPN had infiltrated and could she get an order of hyaluronidase. I was multitasking and relied on the old order and clicked the wrong box: phentolamine instead. (what we use for dopamine extravasation) The patient wasn't on dopamine, pressors or any med that would be treated with that. The computer didn't flash an alert when I ordered it (that I ordered the treatment for a med the patient wasn't on) the pharmacist verified it and sent it (again, despite the fact the patient wasn't on any meds that it would be appropriate to treat.) The RN got it, and though it matched the order, came back to me and said "don't we usually use hyaluronidase?" 

Whoa nelly! Great catch by the RN. Obviously I cancelled the incorrect order, corrected it, and then wrote an incident report for the near-miss. And I don't multitask, even on "easy" orders anymore.  And teach new students that same caution -  don't rely on "easy" orders that you think you could be safe to do while multitasking.  Even the little ones, take the time to give it your full attention.  I've never had the nightmare administration that others describe.  I sat down with my manager to discuss the near miss, and to see if we could get an alert if we order the antidote to something the patient isn't receiving.  And reminder to pharmacy too. I definitely screwed up, and I'm very glad the RN caught it before it reached the patient, but there were a couple of misses down the line that should have caught it too. 

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SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

12 Followers; 54 Articles; 340 Posts; 17,874 Profile Views

5 hours ago, LilPeanut said:

I had an RX near miss - we had an order set for extravasation meds, and they had switched the order they were in before.  I was discussing another patient whose condition was deteriorating when an RN notified me that an IV with TPN had infiltrated and could she get an order of hyaluronidase. I was multitasking and relied on the old order and clicked the wrong box: phentolamine instead. (what we use for dopamine extravasation) The patient wasn't on dopamine, pressors or any med that would be treated with that. The computer didn't flash an alert when I ordered it (that I ordered the treatment for a med the patient wasn't on) the pharmacist verified it and sent it (again, despite the fact the patient wasn't on any meds that it would be appropriate to treat.) The RN got it, and though it matched the order, came back to me and said "don't we usually use hyaluronidase?" 

Whoa nelly! Great catch by the RN. Obviously I cancelled the incorrect order, corrected it, and then wrote an incident report for the near-miss. And I don't multitask, even on "easy" orders anymore.  And teach new students that same caution -  don't rely on "easy" orders that you think you could be safe to do while multitasking.  Even the little ones, take the time to give it your full attention.  I've never had the nightmare administration that others describe.  I sat down with my manager to discuss the near miss, and to see if we could get an alert if we order the antidote to something the patient isn't receiving.  And reminder to pharmacy too. I definitely screwed up, and I'm very glad the RN caught it before it reached the patient, but there were a couple of misses down the line that should have caught it too. 

THANK YOU for doing an incident report on this - you've prevented some harm down the road. I so appreciate the share.

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LilPeanut has 8 years experience as a MSN, RN, NP and specializes in NICU/Neonatal transport.

898 Posts; 5,602 Profile Views

19 minutes ago, SafetyNurse1968 said:

THANK YOU for doing an incident report on this - you've prevented some harm down the road. I so appreciate the share.

I write incident reports always, and encourage RNs to do them too.  Too many view it as being "written up", and some even try and use it as a way to "write someone up", but really, that's not what it's there for. 

Most recently, we did an incident report for an OB who failed to check the mother for HepB during pregnancy. It's state law to check here.  None of the OBs who admitted her noticed she hadn't had it checked this pregnancy either.  Now, it's not to get the OBs in trouble per se, but as neos, we often have a hard time finding the important infectious prenatal labs (that they should really care about too) and if they know the status of them all, they should list them, and if they don't - well, they should send them out.  We had to give the HepB vaccine by 12 hours of life because of no status on mom. 

That's not truly harm to the patient, but it's a huge systematic issue. If they don't have a process for documenting/listing that, one needs to be developed, and if we wrote an incident report every time it happened, they would see it is a big issue. People just have to stop looking at it like a "tattling" system.

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CeciBean has 30 years experience as a ASN, RN and specializes in MICU/CCU, SD, home health, neo, travel.

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I made a terrible error when I was a fairly new nurse. It was partly because I misread a doctor's handwriting. He had written an order for 10 mg. of Vistaril to be given to a severely vomiting child, but to this day I will swear it looked like 100 mg. At that small hospital the pharmacy was not open at night and the supervisor had to  get the medication. She looked at the order also and signed off with me and went and got the medication. The child stopped vomiting and went to sleep and I went on about my duties (I was the only nurse on the unit because that was how it was staffed.) The next day when I came in to work I was hauled in to the DON's office and interrogated. We all looked at the order and I was told I "should have known" the medication. Yes, that was my fault, I should have looked it  up. But I got the blame and the nursing supervisor, who had looked at the order and signed off with me, apparently got off scot free, while I got written up and was transferred off that unit permanently (which was a relief to me, really).

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SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

12 Followers; 54 Articles; 340 Posts; 17,874 Profile Views

41 minutes ago, CeciBean said:

I made a terrible error when I was a fairly new nurse. It was partly because I misread a doctor's handwriting. He had written an order for 10 mg. of Vistaril to be given to a severely vomiting child, but to this day I will swear it looked like 100 mg. At that small hospital the pharmacy was not open at night and the supervisor had to  get the medication. She looked at the order also and signed off with me and went and got the medication. The child stopped vomiting and went to sleep and I went on about my duties (I was the only nurse on the unit because that was how it was staffed.) The next day when I came in to work I was hauled in to the DON's office and interrogated. We all looked at the order and I was told I "should have known" the medication. Yes, that was my fault, I should have looked it  up. But I got the blame and the nursing supervisor, who had looked at the order and signed off with me, apparently got off scot free, while I got written up and was transferred off that unit permanently (which was a relief to me, really).

So sorry this happened to you. It sounds like an honest mistake (so many of our errors are exactly that - honest mistakes.) It seems like having a pharmacist on staff 24/7 would have prevented that from happening. I hope the child was okay. It sounds like you have been able to move forward and are in the process of letting it go - it's just so hard, we hold ourselves to unattainably high standards! Thanks for sharing.

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hannahgb specializes in retire-numerous.

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Agree with Nmbeck--what happened to double checking certain meds--you just did it for safety reasons

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