Would YOU have reported it?

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My patient had 1/2 normal saline running at 100 ml/hour when I assessed him after shift report. The physician came in and ordered to discontinue the normal saline and start D5W at 50 ml/hour. Indeed, he had ordered normal saline yesterday. I took down the 1/2 normal saline, hung the D5W at 50/hour and moved on. I did not tell anyone. I'm considering pulling that nurse aside and letting her know so she may be more careful in the future, as our pyxis system sucks and is easy to make such an error if one is not careful. My patient's condition was stable for my shift. Should I have reported this? I don't want anyone to get in trouble. I know if it had been something dangerous, I would have reported it...but this?

We all make mistakes, right?

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Specializes in OR, Nursing Professional Development.

What is the policy for completing incident reports? If the pyxis makes it easy to make mistakes such as this, an event report can be helpful in identifying systems issues that can help with preventing errors in the future, such as placing lookalike/soundalike medications in different drawers- my OR has done that with different strengths of local anesthetics to help with preventing grabbing the wrong strength accidentally.

However, the fact that you are questioning whether or not to report this is a red flag. Medication errors, whether the patient is harmed or not, need to be reported as per the facility's policy. It's part of practicing nursing professionally and ethically to provide the best care to patients; someone potentially getting in trouble needs to take a backseat to that. Medication errors are at times related to systems issues rather than a single person; reporting it can help fix the system and improve patient care. The doctor also should have been notified- sure, the patient seemed fine, but there can be adverse effects of administering the wrong medication that potentially won't show up until later.

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Thank you for the response. The IV fluids are locked in a cabinet. One must be very careful, because there are several different bags of IV fluids in there! It is very confusing if you are in a hurry!

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Specializes in psych, addictions, hospice, education.

Med errors need to be reported. That's how they decrease. If you don't report one, it's a slippery slope to not reporting the next, and the next and the next.

Facilities have procedures...please follow them. while this patient wasn't harmed, another might have been harmed.

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Specializes in CCRN.

As the others said, it should have been reported. All medication errors should be reported. While the patient was stable, the doctor needs to know that the patient received different fluids than what was ordered. Incident reports are used internally to help ensure that best practice is being used and identify areas for improvement. If the incident reports don't get filled out, then things stay the same.

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Honestly no. It's not a terribly serious error. I would just mention it next time you see her.

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Actually, it has the potential to be a serious error. It can cause fluid shifts and electrolyte imbalances. When labs came back, the provider could order interventions that aren't appropriate because of the incorrect fluids. It definitely should have been reported.

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Wait I'm confused. How is this a med error?

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Specializes in OR, Nursing Professional Development.
Wait I'm confused. How is this a med error?

Because the provider ordered normal saline (isotonic at 0.9%) but the nurse who started the fluids hung half normal saline (hypotonic at 0.45%). Instead of maintaining cellular vs. vascular fluid levels, the hypotonic solution would cause fluid to shift from the vascular system into the cells, possibly leading to cell lysis and vascular volume depletion.

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Specializes in ORTHO, PCU, ED.

You didn't say when the D5 was ordered? I assume on previous nurses' shift and she did not see the new order?

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Specializes in ORTHO, PCU, ED.
Because the provider ordered normal saline (isotonic at 0.9%) but the nurse who started the fluids hung half normal saline (hypotonic at 0.45%). Instead of maintaining cellular vs. vascular fluid levels, the hypotonic solution would cause fluid to shift from the vascular system into the cells, possibly leading to cell lysis and vascular volume depletion.

OP, is this correct? I'm confused.

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Specializes in OR, Nursing Professional Development.
OP, is this correct? I'm confused.

My patient had 1/2 normal saline running at 100 ml/hour when I assessed him after shift report. The physician came in and ordered to discontinue the normal saline and start D5W at 50 ml/hour. Indeed, he had ordered normal saline yesterday. I took down the 1/2 normal saline, hung the D5W at 50/hour and moved on.

Emphasis mine, but it does indeed appear that the order previous day was for normal saline but half normal saline was running.

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