I was working a night shift, which to this day I truly detest. When I got report, I found I had a patient in acute alcohol withdrawal (which in and of itself makes me furious, because there is no excuse for a hospitalized patient to suffer DT's if someone knows what they're doing, but I digress.)
Anyway, back to this unfortunate soul.
Because he was delusional and combative, he was restrained so he couldn't yank his IV out for the 10th time. They had also wrapped his IV site with kerlex as an added precaution...maybe if he couldn't find it he'd leave it alone. He was also being transfused with a couple of units of blood.
When I got there, he was nearly through the first unit, and I was to finish that and hang the next one. Well and good. Or so I thought. I started the second unit, but I had one hell of a time infusing it. I literally forced it in with the help of a pressure bag, and I am not kidding when I say it took a good 6 hours to get that blood in. Meanwhile, the patient was getting more and more agitated, which I attributed to his withdrawal.
Finally, mercifully, the blood was in so I opened up the saline to flush the line. But it wouldn't run. All of a sudden I realized, with absolute horror, what had happened.
I cut off the kerlex covering the IV site hoping against hope I was wrong, but alas, I wasn't. Yes indeed, I had infiltrated a unit of blood. I hadn't even bothered to check the site.
No wonder he was so agitated, it probably hurt like hell.
An hour later my manager showed up, and I told her what happened. She was probably the most easy going person I've ever known, and she told me not to worry about it.
I said "Listen to me, I infused an entire unit into his arm, go look at it." She did, and came out and told me to go home. I expected consequences, but never heard another word about it. But I am here to tell you I learned from that mistake.
He assumed the nurses would know that the Elixir would be given orally. This nurse did not. Nor did she question the order. Morphine Elixir is a beautiful bright blue color. I cannot think of any IV medication that is blue. However, this young nurse drew the amount needed into a syringe and injected it into the patient's IV. It was then that the nurse began to question her decision to inject this medication IV. The patient suffered no adverse effect, but we did some serious counseling with this nurse and had her complete a medication administration program with the education nurses and put her on probation.
I had decided not to write of a similar story because I didn't think it would be believable but after your Morphine story I have to tell this one. I certainly didn't believe it when I was told, I had to see the paperwork for myself.
An older hospital RN had an order for 100mcg of Levothyroxine IV qd. Pharmacy printed the sig on the label correctly however the person filling the baggie put a 100mcg Levoxyl tablet in the baggie. For whatever reason this error was not caught in the pharmacy and the drug was sent to the floor.
The nurse took the tablet, crushed it, mixed it with NaCl, heated it, drew it up in a syringe and injected it IV. She thought it was okay because she used a filter needle.
The nurse should have probably retired a long time previous to this incident but she didn't. So the hospital gave her a choice, either retire voluntarily or be terminated. She retired. I suspect she probably lost her license but I don't know that for sure.
I don't understand errors such as this or the one you posted about the Morphine. I can see errors where you give the incorrect dose or incorrect drug, but how could someone crush a tablet, a common tablet and think this is okay? Or how could someone draw up a dose in a syringe from a non sterile bottle? Seriously, what would you do... pour a bit into the cap of the amber bottle and draw it up? Isn't that about the same thinking as drawing up the drug from a suppository? How can a nurse not know better?
An RPh I know thought that if you used a small enough micron filter that it would filter out all of the bacteria. How can someone get through 4-8 years of college and not realize this? The RPh defended the nurse with the Levothyroxine tablet because if she used the correct filter she thought it would be sterile.
The morphine, the tablet given IV... that isn't human error, that is something much different, I just don't understand how anyone could make that kind of error. Again, wrong dose, wrong drug, wrong frequency... I understand. But the others I just don't get it.
The spooky part of any med error for me are those that might have happened and I never realized it. You know, the big 'what if' questions. Most med errors can typically be reversed but only if we are aware we did it. Something I started doing a long time ago was after my checks and rechecks when I give a med I usually tell the patient what each drug is and what it is for as I am giving it. Something about saying it outloud makes a difference and often times the patient knows what they are supposed to be getting so that is yet another check.
Specializes in med/surg, telemetry, IV therapy, mgmt.
An older hospital RN had an order for 100mcg of Levothyroxine IV qd. Pharmacy printed the sig on the label correctly however the person filling the baggie put a 100mcg Levoxyl tablet in the baggie. For whatever reason this error was not caught in the pharmacy and the drug was sent to the floor. The nurse took the tablet, crushed it, mixed it with NaCl, heated it, drew it up in a syringe and injected it IV. She thought it was okay because she used a filter needle.
The nurse should have probably retired a long time previous to this incident but she didn't. So the hospital gave her a choice, either retire voluntarily or be terminated. She retired. I suspect she probably lost her license but I don't know that for sure.
I don't understand errors such as this or the one you posted about the Morphine. I can see errors where you give the incorrect dose or incorrect drug, but how could someone crush a tablet, a common tablet and think this is okay? Or how could someone draw up a dose in a syringe from a non sterile bottle? Seriously, what would you do... pour a bit into the cap of the amber bottle and draw it up? Isn't that about the same thinking as drawing up the drug from a suppository? How can a nurse not know better?
I'm with you on this. I was flabergasted when I heard about the Morphine incident. My own first thought had been "didn't she realize that it was blue liquid she was shooting into the IV line?" With the Insulin thing I was impressed that the mentor was able to just stand by and watch this poor girl drawing up Insulin in an IM syringe. She later told me that she was more fascinated with the idea of trying to figure out what might be going on in her mind. As I recall there were many other incidents with this graduate nurse, but this one stands out in my memory. I do remember that who ever worked with her watched her like a hawk because they were all afraid she was going to hurt someone.
This also reminds me that it is not as easy to terminate someone as you would think. At least at that hospital we had to have the written documentation to back up incidences like this. And even then, it was reviewed by the Personnel officer and the final decision to terminate any nursing personnel was ultimately made by the Director of Nursing with the Personnel Director. So, for those out there who wonder what administration is waiting for to fire people like this, you have to know that they need clearly written accounts of these incidents when they occur. Unless the mistake is a real doozie, these written up incidents eventually add up in a persons file. And, I don't care what they tell you, nothing like those kind of incidents, ever--ever--gets thrown away. They are kept in order to establish a pattern that leads the genius in question OTD (Out The Door).
Back in the olden days, when they had glass syringes, they also had tablets of injectable morphine which were crushed and mixed with diluent and then given IM.
Back in the olden days, when they had glass syringes, they also had tablets of injectable morphine which were crushed and mixed with diluent and then given IM.
Back in those olden days when I started my nursing career (diploma grad 1974) there were several medications we mixed with a sterile dilutent and gave IV. I don't even recall using a special filter.
Interesting that they fired the RN who gave the levothyroxine and that she maybe lost her license. I wonder what happened to the pharmacist who sent down the med?
In this case I don't actually consider this a medication error, but a communication error.
Back in those olden days when I started my nursing career (diploma grad 1974) there were several medications we mixed with a sterile dilutent and gave IV. I don't even recall using a special filter.
Interesting that they fired the RN who gave the levothyroxine and that she maybe lost her license. I wonder what happened to the pharmacist who sent down the med?
In this case I don't actually consider this a medication error, but a communication error.
I don't know what happened to the RPh. She is gone but I don't know if that was on her own or if she was fired. Due to the huge number of mistakes I can only assume she was fired but I am speculating.
As for a med error vs. a communication error... I can't see how it was anything but a med error. The label on the baggie was quite clear it was a 'vial' of Levothyroxine. Inside was a tablet. That was a med error on the part of the pharmacy since it was filled incorrectly. The fact that a nurse with a great deal of experience took an unsterile tablet, crushed it up, heated it, drew it up in a syringe and injected it knowing the drug comes in a vial...that was sheer stupidity. In no way is that a communication error IMNSHO.
We have come a long way in administering meds since the 40's when this was likely common practice. We have also come a long way since the 70's as well.
While this was certainly a mistake on both departments of the hospital, I can't see how anyone could consider such stupidity a communication error.
Out of curiosity, what oral tablets did you give in the 70's by crushing, heating, and drawing up to give IV without a filter?
We have come a long way in administering meds since the 40's when this was likely common practice. We have also come a long way since the 70's as well.
While this was certainly a mistake on both departments of the hospital, I can't see how anyone could consider such stupidity a communication error.
Out of curiosity, what oral tablets did you give in the 70's by crushing, heating, and drawing up to give IV without a filter?
Yup, time keeps on marching by for all of us. The only meds I gave in the 70s that were sent in tablet form for IM or IV use were morphine and dig. I'm sure there were others, but I didn't give them. And we never heated anything up, the tablet just dissolved on its own.
I think there is a culture in nursing to hide our mistakes out of fear of being considered stupid or incompetent. I can certainly understand why this error occurred, and I really don't think it had anything to do with stupidity. Maybe I should have said systems error, not communication error (although it certainly ended in a med error). If the pharmacist hadn't sent the incorrect form of the drug to a nurse who had previously crushed tablets for parenteral use.... I doubt this error would have happened to a nurse who didn't realize that meds could and were safely given this way.
I think by sharing our mistakes without judgement we can help everyone avoid the same or similar mistakes in the future.
Yup, time keeps on marching by for all of us. The only meds I gave in the 70s that were sent in tablet form for IM or IV use were morphine and dig. I'm sure there were others, but I didn't give them. And we never heated anything up, the tablet just dissolved on its own.
This is interesting. I graduated in 84 and I am totally unaware (or I just don't remember) morphine or dig coming in tablet form for injection.
Was this JUST for injection or was this an oral tablet that was used for injection? Was it the same stuff we use today?
Were those drugs not available in injection form at that time?
Please don't misunderstand my questions to be doubting you, I am not. I just find it interesting. I didn't know this still happened in the 70's. I really thought the practice went out somewhere in the 40's.
Was this a sterile tablet or was it what we give today for oral use?
This question wasn't addressed to me, but in the 70's, there were injectable morphine tablets which were put into a syringe and the diluent dissolved the tablet, this was for IM injection. I don't know about IV. I also worked with glass syringes and reusable needles.
Was this a sterile tablet or was it what we give today for oral use?
As far as I remember it was the same stuff. I know, I'm amazed at what's changed over the past few years.
This is off topic, but back in the 70s we hung alcohol drips and gave IM paraldehyde for DTs in the ICU. Paraldehyde was really stinky and had to be given in a glass syringe because it would melt plastic. We often gave 10cc in one IM injection. I'm pretty sure its use is contraindicated these days (at least the injectable).
We had arterial lines that were hooked right into a regular BP manometers. Rotating tourniquets were the in thing for patients with pulmonary edema. I remember how cool it was to get automatic ones (instead of using real rubber tourniquets).
Yeah, a lot of stuff has changed, but I think the heart of nursing has pretty much remained the same.
Oh, and to go back on topic a bit - how do y'all handle medication errors in your facilities? I mean, is everyone required to fill out an incident report, go to committee, what? I know there is a huge emphasis on preventing medication errors these days, I just wondered how it's being handled.
Oh you poor dear. At my hospital, it is protocol that we have to have 2 nurses check and sign each others insulin. No matter what kind, what dose. I guess I shouldn't complain.
My error has kept me from working since the day it happened. I so terrified that I may make another mistake which may lead to a patients crash or even death. It was a busy day and I was overwhelmed (still no excuse) and my patient was on a sliding scale insulin. I took the blood sugar and she required FIVE (5) UNITS of insulin. to this day I do not know what was going through my mind but I pulled back to FIFTY (50) UNITS instead of the minimal FIVE (5) she needed. I did my checks that it was the proper insulin. I took the patients medication profile to her bedside and compared her armband to the profile and I stated to her that I was there to administer her insulin.
Still not knowing that I had done the error I left the hospital at the end of my shift which was about 45 minutes later. I had helped her with her tray and asked her if there was anything I could do for her before I went off shift. (because sometime report & shift change take a while), she replied no.
Oh you poor dear. At my hospital it is protocol to have 2 nurses check off and sign an insulin dose. I guess I shouldn't complain about it.
I was at dinner with my husband at a resturant and while eating my soup, which was the first part of my meal, IT HIT ME WHAT I HAD DONE! My husband saw my face and asked me what was wrong I immediately grabbed the cell phone and tole my husband to just leave money and drive me to back to the hospital. I called the unit and told them about the error - they said 50!?!?!?!?! I said yes I will be there in 5 minutes. They changed her iv fluid to 50% dextrose and ran it at 100/hr. I stayed with her doing continuous bld sugar tests until midnight. Her BLOOD SUGAR never dropped below 8.1 - in Canada (Ontario) normal blood sugar levels are between 3 and 7.
I was praised and praised for coming back and admitting my mistake. I haven't worked as an RN since.
Oh, and to go back on topic a bit - how do y'all handle medication errors in your facilities? I mean, is everyone required to fill out an incident report, go to committee, what? I know there is a huge emphasis on preventing medication errors these days, I just wondered how it's being handled.
At the hospital I worked at being going to the company I'm with now, med errors meant that you had to complete an incident report but nurses could not be reprimanded for them. If it was a problem they could be asked to have more CEs or some educational process could be implimented but no write ups or any other such procedure. The thinking was if a nurse would be in trouble for making a med error, she would be less likely to report it.
If it was a chronic problem and education wasn't working it was reported to the BON and the nurse was let go. But a write up for a med error... it didn't happen.
This is off topic, but back in the 70s we hung alcohol drips and gave IM paraldehyde for DTs in the ICU. Paraldehyde was really stinky and had to be given in a glass syringe because it would melt plastic. We often gave 10cc in one IM injection. I'm pretty sure its use is contraindicated these days (at least the injectable).
I remember paraldehyde and you are correct, it does smell bad. I also recall one New Year's Eve giving a patient an alcohol IV for drinking auto radiator coolant. That was the cure at the time. Never had such a patient since then so I don't know what the treatment is now.
PicklesRN, RN
75 Posts
I had decided not to write of a similar story because I didn't think it would be believable but after your Morphine story I have to tell this one. I certainly didn't believe it when I was told, I had to see the paperwork for myself.
An older hospital RN had an order for 100mcg of Levothyroxine IV qd. Pharmacy printed the sig on the label correctly however the person filling the baggie put a 100mcg Levoxyl tablet in the baggie. For whatever reason this error was not caught in the pharmacy and the drug was sent to the floor.
The nurse took the tablet, crushed it, mixed it with NaCl, heated it, drew it up in a syringe and injected it IV. She thought it was okay because she used a filter needle.
The nurse should have probably retired a long time previous to this incident but she didn't. So the hospital gave her a choice, either retire voluntarily or be terminated. She retired. I suspect she probably lost her license but I don't know that for sure.
I don't understand errors such as this or the one you posted about the Morphine. I can see errors where you give the incorrect dose or incorrect drug, but how could someone crush a tablet, a common tablet and think this is okay? Or how could someone draw up a dose in a syringe from a non sterile bottle? Seriously, what would you do... pour a bit into the cap of the amber bottle and draw it up? Isn't that about the same thinking as drawing up the drug from a suppository? How can a nurse not know better?
An RPh I know thought that if you used a small enough micron filter that it would filter out all of the bacteria. How can someone get through 4-8 years of college and not realize this? The RPh defended the nurse with the Levothyroxine tablet because if she used the correct filter she thought it would be sterile.
The morphine, the tablet given IV... that isn't human error, that is something much different, I just don't understand how anyone could make that kind of error. Again, wrong dose, wrong drug, wrong frequency... I understand. But the others I just don't get it.
The spooky part of any med error for me are those that might have happened and I never realized it. You know, the big 'what if' questions. Most med errors can typically be reversed but only if we are aware we did it. Something I started doing a long time ago was after my checks and rechecks when I give a med I usually tell the patient what each drug is and what it is for as I am giving it. Something about saying it outloud makes a difference and often times the patient knows what they are supposed to be getting so that is yet another check.