What errors have you caught? (Docs, Pharmacy, etc.)

[fedupnurse]

A couple of months ago one of the endocrinologists wrote an order for insulin scales. One was for 8 am to 8 pm and the other was 8pm to 8 am. When I looked in the computer to sign off my 8 pm dose I saw 2 insulin scales but the pharmacists had put them in for 8p-12mn-4a and 9p-1a and 5a. Hello!!!! SO I called her and she said "I don't know how to change it in the computer." SO I said "So you are just going to leave it like that??" She said "yeah." SO I had to fill out one of the variance sheets and call the supervisor and tell my charge nurse. It was fixed before the end of my shift but still, how scary is that??? I can easily see this patient going all day without insulin coverage.

SO what errors have you seen and found before any harm was done to the patients?

[RNinICU]

Dilantin instead of dig in a patient's med drawer. The envelope said digoxin, the vial was dilantin.

[OBNURSEHEATHER]

Originally posted by Pharmacist Joe

But let's not get high and mighty, here. I've caught my share of killer nurse and MD errors, too. Face it: we are human beings and we make errors.

I don't think anyone was getting high and mighty Joe. The thread clearly states "docs, pharmacy, etc". If you got some good nursing ones, share them with us please. Nurses learn best from experience.

Heather

[mother/babyRN, RN]

Pharmacist Joe taking things a little personally here don't you think, ESPECIALLY on a nurses site......We find many of our errors are in part due to the fact that pharmacy assistants are charged with doling out the meds that go to the floors...THAT doesn't seem something that should be sanctioned, to me. Would be as though your CNA was allowed to distribute meds...

[Pharmacist Joe]

Lot's of good discussion on this issue! The reason a pharmacist is chiming in on a nurse's web site is that this issue transcends departments. No, I am not taking this personally (I used to, but now I'm older and wiser). We need to look at med errors as something that happens because we are human. And we need to put in systems that prevent or at least mitigate med errors (they will happen--I guarantee it). Examples of systems: unit-dose, robotic dispensing, bedside bar-code scanners, a medication safety committee (nurses, pharmacists and physicians) that actually accomplishes something. If you don't have such systems in your hospital, get them started! If nurses are getting the blame for med errors, bring your hospital up-to-date on this issue! We need to get nurses, pharmacists, docs (resp therapists? administrators? others?) working together on this issue to protect our patients.

[nell]

Well, Pharmacist Joe, I can tell that you aren't the Joe that works in our pharmacy. I don't think you would argue with me about re-mixing a TPN on a

Also, we get argued with about ordering Survanta all of the time. One Pharmacist wouldn't send us the vials - he wanted to know the exact dose so he could draw it up (this is done with sterile technique just before administrating via ETT with sterile technique...). We need to keep some on the unit because the Pharmacy isn't open at night, but it's like pulling teeth to get it. It's expensive, sure, but what do they think we going to do - sell it on the black market???

Considering that Pharmacists get paid about 1/3 more than nurses, I expect them to occaisionally use their brains, not just "fill orders".

[fedupnurse]

I agree, Pharmacist Joe, we do need to try to have as few errors as possible. I think we should start with the drug companies. Let's have a unique label for each and every drug. This look a like type of labeling is just downright frightening! Next, let's require the hospitl execs to require that all orders be placed in the computer. My hospital doens't require this and let me tell you, handwriting of most docs is disgraceful! Next, let's not pull nurses to units or department's they are not familiar with. Would anyone out there go to a podiatrist for chest pain?? Next let's make the reporting of errors less cumbersome. We have a medication variance form that could scare the bleep out of even a seasoned veteran of hospital forms. Next, let's do something about medical/surgical etc. residents and attending MD's who think they know everything and then some and berate nurses for pointing out that they are ordering a sentinel dose of a medication. You'd be amazed at how many nurses wll forever keep their mouths shut after being reemed out just once-even when they are right!!!! I'm sure there are a gazillion suggestions we can all come up with but what it really comes down to, as always, is staffing! There aren't enough pharmacists or nurses to get the job done right. I cannot think of 2 more important departments in terms of life and death than nursing and pharmacy!

Thanks for your input Joe, I appreciate it.

[nursegoodguy]

I worked with a nurse who had two new patients in the same room. Patient A fell and had an obvious broken hip. The nurse ran to the desk to call the family and doc to get the patient shipped out and as she was paging the doc I noticed that she had patient B's chart so I asked are you sending that patient to the hospital and she said yes and I said but it was patient A who fell... She said Oh my God! We did kind of chuckled afterwards at what almost happened... The facility liked working us extremely short staffed! They'd give you a hall or 2 or 2 and 1/2 it's no wonder people were running too fast!

[semstr]

ok, this happened shortly after my training finished and I was "freshly" licensed", waaayyy back in 1982.

We had a young female with pleura-carcinoma, the onc. doctors decided to give her chemotherapy injected right into the tumor.

My supervisor and I prepared everything, including the local lidocain and the Vincristin. (Note: Vincristin was red and 20ml, Lidocain, well clear and 5ml)

To make sure everything was as ordered, we had it triple checked by another RN, we sticked the vials to the syringes.

Then we had another patient with a cardiac arrest, so we did CPR and the whole show.

After we came back, we couldn't find our syringes, so I went to this patient and she lay in bed, with the most awful colour you can imagine and crying in pain. So I looked at her ribcase and made a doubletake back............. her side was black!!

I run for the supervisor, who had one look and paged the doctor stat. He came had one look and called the OR stat.

Patient was operated on (they had to take the biggest part of her skin and muscles of, because of the necrosis. She lived though!!)

So what happened? A senior resident, changed the lidocaine with the Vincristin and injected the Vincristin intra- and subcutaneus!!

He tried to blame us nurses for not putting the right substance in the syringes, but he soon knew this couldn't hold, since we fished the syrignes plus the still attached vials out of the dustbin.

He was fired right away, since he did a few other things before this incident, which weren't very nice to patients, being very rough, unnecessary bloodwork, sticking 5-6 times trying to draw blood, well he was a A$$hole through and through

I am glad to say this woman survived, but it took a long time for her to look "normal" again.

The paperwork on this one was unbelievable!!

Take care, Renee

[aimeee, BSN, RN]

Twice I found that pharmacy had sent hydralyzine instead of hydroxyzine. Boxes were marked hydralyzine as the order read but the pills inside were hydralyzine. Another time we were sent 100 mg. Thorazine instead of 10 mg.

[nightingale, RN]

:eek: