Wrong label on drip..suggestions?

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Specializes in Critical Care.

To make an incredibly long story short. I had an amiodarone drip for a PT who was in persistent SVT. The drip was supposed to start at 1 mg/min after the 150 mg bolus, 1mg/min on standard concentration (900mg/500ml) is 33.3 ml/hr then to be reduced to 0.5 mg/min which is 16.6 ml/hr. The pharmacy sent up the glass bottle of amiodarone and i gave the bolus followed by the maintenance infusion, the label on the bottle said 900mg/500ml which give you a 1.8mg/ml conentration. Before we start drips we are supposed to use our monitors which come with a drug calculator an we are supposed to punch the numbers in and then print out the sheet and 2 RNs are supposed to sign off on it . I check the label and did my calculation on the monitor and and double and triple check the concentration and rate with a second nurse as Im supposed to. Around 5 o clock I notice the bottle running out and since we do not have a 24 hr pharmacy I was forced to mix my own drip. The supervisor and an Another staff nurse (who is also a supervisor) questioned how a 500 ml bottle ran out so fast, as did I. The other nurse even went in to check the label on the bottle and saw that the label said Amiodarone 900mg/500ml = 1.8 mg concentration. When the on shift supervisor came up she looked at the bottle and said that's a 250 bottle, which it was. Obviously the pharmacist who mixed the drip put the wrong label on it. I called the MD who gave me the order who is an EP doc and he wasn't even phased by it. He said not to worry and that as long as his HR and BP are fine it's ok. So really we are not sure if the PT got double the dose or half the dose, because the label and the concentration was all wrong. So now I'm not only ****** off because I was involved in another med error in which a nurse hung Levo instead of neo and I'm the one who caught it 30 min into my shift and somehow ended up getting a final written warning because I did not flip the bag around to check the drug during report, I took that on the chin and told myself I'd be more careful. I've been meticulous about my drips and things and now I'm scared that I'm gonna get screwed over something that I didn't do. I have a funny feeling that they (management) will find a way to fire me because I already have a warning on my file. I'm honestly not sure what to do. And I honestly don't feel that this was really my fault. I followed what I'm supposed to do and right now, not only am I ****** but super scared on what is going to come of this. Idk if anyone has any suggestions or even just words of encouragement...I'm just so angry right now I'd like to punch the pharmacist in the face to be honest.

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Sorry to say, but that's why you always double, triple, quadruple check everything you hang or that is infusing. Especially with Amio I've seen them come up in really messed up concentrations and pharmacy has to remake me tags for the proper rate, or send an entirely different bottle or bag. I think the staggered dosing is hard for the docs and pharmacists to grasp for whatever reason, as neither of them ever seem to get it right the first time. Not that I'd probably be much better, but it's been an ongoing issue from what I've seen.

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Specializes in multispecialty ICU, SICU including CV.

I would fill out an incident report on this myself and beat them to the punch. If your facility puts this in your file and tries to pin the blame on you/discipline you, that's crap. This was FIRST and foremost a pharmacy error -- yes, it got through nursing, but I think that you could make a case for not knowing what was up (because you didn't) especially if the label on the bottle covered up the total volume on the bottle (where it said 250ml on the bottle itself.)

My hospital had a rash of errors similar to this and it was decided to go with one standardized drip concentration for every vasoactive/antiarrhythmic gtt across the board, so there was never any question of what you should get (we make exceptions for those that need their gtts concentrated, but that's it.) There was a root cause analysis done of several med errors and that was the solution my facility came up with. All gtts are also mixed in the pharmacy unless there is a dire emergency in an attempt to keep things standardized.

If this kind of stuff goes on regularly, it's a system problem. Don't be so hard on yourself (there wasn't harm to the patient) and see if you can get things fixed up instead.

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Specializes in multispecialty ICU, SICU including CV.

Oh, and BTW I think it's crap that you it went in your file when you found the levo/neo mixup 30 minutes into your shift as well. Sounds to me like you were the one that identified that error -- correct me if I'm wrong!! Was that gtt mixed on the floor? If that had gone through the pharmacy, I bet the right drug would have been hanging -- that was an error on the part of whoever prepared/hung it, I would bet.

Your facility sounds horrible to me and like they are on a witch hunt. Yes/no?

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Specializes in NICU.

I hope you wrote the pharmacist up.

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Specializes in critical care, PACU.

was it 450mg in 250mls? I had a similar experience last week and the concentration and dose to patient were same but volume was not.

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Specializes in Critical Care.
I hope you wrote the pharmacist up.

Hell yea! I did write that pharmacist up.

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Specializes in Critical Care.
was it 450mg in 250mls? I had a similar experience last week and the concentration and dose to patient were same but volume was not.

See that's the thing. I guess we don't know unless we talk to the pharmacist about what she really put into the bottle because if she did then the patient did get the right dose of meds because even at that concentration the rate on the pump should still be 33.3 ml/hr which comes out to 1mg/min. I spoke with my NM and pretty much she obviously wanted to know what happend and i did everything the way that we are supposed to. She asked me if she thought that it would have been caught before I said that I honestly did not know. And my reasoning why is this, there were 2 other people who came in and looked at the label and thought it was a 500ml bottle. The light bulb went on when the onshift sup. came up with a legit 500ml bottle and you can see the obvious size difference. the 500 ml is like a 2L bottle of pepsi, a obvious difference for someone who has hung this drip a million times. This would only be my 3rd time hanging it to be honest. I said if the pharmacist had not covered up the part of the bottle that said 250ml 5% dextrose I think she would have caught it before she sent it up and I damn well know that I would have caught it because it's in big green letters in CAPS you cant miss it. I went and looked at the rest of the pressors we use and if you look on the bag you can clearly see the ml marks on the side of the bag. AND you can see where it says 500cc 0.9% NaCl etc, on all of the other drips those were not covered. I was set up by pharmacy and she even said it. I accepted accountability for hanging the drip and i said but this is (as someone already said, and yes i used those exact words to my NM) first and foremost a PHARMACY issue. So right now im waiting on what is going to happen to me as far as discipline, considering I got my final written with that stupid ass levo/neo incident idk what the fallout from this will be. Sucks to be me right now. But thank you to everyone who commented.

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Specializes in floor to ICU.

Wow, sorry this happened. A little off topic but years ago I was working pedi. My pt was about 8yrs old and I hung the antibiotic that was scheduled. I had checked the label before infusing. About 5-10 min into the infusion, I was called to the room because the pt was complaining of burning from IV. I stopped the IV and assessed the site (thinking it was infiltrating or going bad) but the site looked great. I pulled the bag down and looked at the bag again- it was labled correctly. Upon closer inspection I realized that it was a premix of 20mEq of potassium in 100ml of NS with an antibiotic label over the top of it. :eek:

Scary when stuff like that happens...

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Specializes in Critical Care.

this has just made me be just THAT more careful with everything. People might consider it a little to much now, I double, triple, quadruple and quintuple check everything now. Lesson learned

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Specializes in CVICU.

Wow both of those situations suck (the amiodarone and the potassium mix-up). Now I seem to remember something from school regarding this. Its my understanding that nurses are NOT responsible for knowing that a med labled "X" is anything other that "X". For instance, if a white pill comes up in a pharmacy packaged packet and the label says vicodin but its actually metoprolol, thats not on nursing, its on PHARMACY. I don't see how this is much different.

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...i'm just so angry right now i'd like to punch the pharmacist in the face to be honest.

firstly, it is inappropriate as well as unlawful in most states, to advocate personal violence on a public forum. all should take note here, forums such as these, are no different than standing on your front porch will a bullhorn. the pharmacist, upon seeing this post and identifying the poster, could initiate all manner of legal mayhem if so desired.

that aside.....

you have a reasonable (and legal) expectation that what is labeled on the medication is in fact what is within the container / package. experience could possibly have helped you identify the sizing / volume error, (as no doubt the supervisor spotted it), however, this particular monkey would still be partially on your back due to the presence of that 250 ml bottle. the prudent nurse standard applies here.

first order of business is patient outcome. notice the physician's response and concern, (the patients current condition). when it is all boiled down to the bare nuts and bolts, your job amounts to handing over the patient at the end of your shift with the appropriate and timely interventions in progress, even the patient is doing badly. (was this in fact the case?), is the second hurdle.

initiating your hospital's medication error reporting protocol would be mandatory in this case, again the prudent nurse standard.

lastly, when faced with a potential disciplinary action, take a moment to "step away" from it all before responding. wait until the shift is over to think things through.

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