So, just got home from work and probably won't sleep too well tonight because I just made a rather large med error. Had a two week old come in with a 101.6 rectal temp. I get a far more experienced nurse to come and help with IV, foley, etc., as I didn't feel it would be safe for me to attempt to care for this baby on my own. So we draw labs, get urine, and do an LP. After the LP, the MD orders two abx (300 mg cefotaxime and 300 mg ampicillin) and a 120 ml NS bolus. I double check my math for how many ml's I need to infuse with another nurse (we don't have 24 hr pharmacy) and hang both, get them infused before I take her to the peds unit. Also, the MD orders 90 mg Tylenol PO. I grab that before I take her up as well. Baby is looking/acting far better and I take her to the floor with Mom.
Well, about an hour later, the peds nurse calls and says she is getting a weight of 3.52 kg, compared to our 6.1 kg. Apparently, the triage nurse had charted the weight wrong from the scale (charting lbs as kg) and it was never caught by myself or the doc.
We ran through the dosages for the meds we gave and, according to the mg/kg/day amounts, we are in the safe range. However, I feel absolutely horrible about all this right now. I'm usually extremely careful with dosages, especially with babies, but somehow the weight just not looking right didn't ever click in my head. I think not having to do any dosage calculations myself helped me to not catch the weight error, but that's still no excuse for this to have happened. I feel AWFUL.
I guess the point of this thread is to sort of vent my frustration with myself. I dunno. Anyone had a similar situation occur?
