What Is It About The Number "Ten" and Dosage Errors?

tyvin, BSN, RN · May 13, 2011

I believe we're talking about mg per ml ratios. With my experience it's been done with the multi-dose liquid draw bottles of morphine that come in multiple doses ranging anywhere from 10mg per ml to 50mg per ml and on up. You grab the wrong bottle and don't check ... well there ya go.

AngelicDarkness · May 13, 2011

My work has electronic MARs so I'm always worried the pharmacy will have a hard time reading my orders and not put the decimal in the right place. I've heard some horror stories from my DOC who has transcribed orders only to find the MD wrote them with the decimal in the wrong place making the dose 10 times the required amount. What a scary thought.

Turd Ferguson · May 13, 2011

The metric system operates on the power of ten, and when calculating dosages based on mg/mL it's very easy to misplace a decimal (provider, secretary, pharmacy, nurse- that's at least 4 people that have to get it exactly right every time)

tvccrn, ASN, RN · May 13, 2011

My work has electronic MARs so I'm always worried the pharmacy will have a hard time reading my orders and not put the decimal in the right place. I've heard some horror stories from my DOC who has transcribed orders only to find the MD wrote them with the decimal in the wrong place making the dose 10 times the required amount. What a scary thought.

This simply outlines the importance of the nurses knowing the correct dosage for the medications they are giving. Whether it is the amount or the form (mg vs. mcg), if you know what the normal dose is then you can clarify an order that is incorrectly written.

mindlor · May 13, 2011

Ultimately at the very end of the day I will pin this on hospitals not staffing properly. it is time for legislation to mandate staffing levels.

AJPV · May 13, 2011

Whenever I'm about to write out digits, I always slow down and make sure each digit is clear, that there is enough spacing around each digit, and that the decimal point is big enough to be obvious. You can afford to have a little sloppier handwriting when writing many words that can be figured out from context (well, except for certain med names), but I think it's always worth the time to slow down for the dosage digits, and units for that matter.

systoly · May 13, 2011

This simply outlines the importance of the nurses knowing the correct dosage for the medications they are giving. Whether it is the amount or the form (mg vs. mcg), if you know what the normal dose is then you can clarify an order that is incorrectly written.

Absolutely. As should the pharmacy.

Chemistry Sux · May 13, 2011

med dosage erroros scare the crap out of me. I'm just a student, but everyone talks like they are very common and SERIOUS when they happen. What causes this? Is it as simple as not checking and double checking the meds you're giving? Is it transcription error? Is it messy Dr. had writing? Are there ways to avoid this by simply paying close and careful attention while administering meds?

Esme12, ASN, BSN, RN · May 13, 2011

med dosage erroros scare the crap out of me. I'm just a student, but everyone talks like they are very common and SERIOUS when they happen. What causes this? Is it as simple as not checking and double checking the meds you're giving? Is it transcription error? Is it messy Dr. had writing? Are there ways to avoid this by simply paying close and careful attention while administering meds?

All of the above.........paying attention is never easy when there are always multiple distractions at the same time.

Esme12, ASN, BSN, RN · May 13, 2011

Ok was reading a news story from New Zealand hospital coping with several med dosage errors by nurses, with a few of them causing the ultimate poor outcome - death. What struck me is that as with reported errors here in the United States making the news recently the dosage was calcuated incorrectly by the nurses so ten times the correct amount was given. Why is it always "ten" and is there some sort of worldwide problem working with decimal points?

BINGO! I also think all of the checks,interference, noise, electronic noise and the addition of the "nonsense" manditory documentation has put us in a place that we can't see the forrest for the trees......

DoGoodThenGo · May 13, 2011

med dosage erroros scare the crap out of me. I'm just a student, but everyone talks like they are very common and SERIOUS when they happen. What causes this? Is it as simple as not checking and double checking the meds you're giving? Is it transcription error? Is it messy Dr. had writing? Are there ways to avoid this by simply paying close and careful attention while administering meds?

It's all of the above.

The "five rights" aren't some abstract theory, but when properly applied guide one through giving meds from everything to dosage calc to administration. Indeed will go further and say even from the time the med order is picked up.

As a student the best thing is to start with is good rock solid habits and methods that allow you to reach >90% accuracy in med dose calc. That is the number hospitals will look for as a passing grade in making job offers (if not 100%), and as I'm fond of saying, if you can only manage say 75% in all one's grades as a student when it comes to meds that translates into an error rate of 25%. This means a quarter of the time you give meds there is a good chance it will be done incorrectly, and that is totally unacceptable.

The next part only comes with time and experience as a licensed RN, but you can start building good habits in school as well. You need to build a rock solid knowledge of common medications, this includes a "core" of med/surg meds and then also whatever drugs are particular to your special area of practice. There are PDRs and other reference materials in nurse's stations and med rooms for a reason. When you come across a new drug on a med order and or it is something you aren't familiar with, the same thing applies as when one is in school; look it up!

Finally though it may seem hard to do at first, if you do come across a med error in how an order is written, and or you think even as written by the doctor your patient *might* be harmed by administration, you need to put on your critical thinking cap and make a judgement call. Call your charge or a supervisor in for advice, and or if required contact the doctor. Yes he or she will probably call you very nasty names and or threaten your job, but remember this: once you administer a med you OWN the outcome. Yes the order may have been written incorrectly, or the pharmacy made an error, or whomever picked-up/took the order got it wrong, but it's your hinne (and license) on the line.