21 replies to this topic

[NawlinsGirl]

For our collective benefit, list some of the med errors you've seen committed or caught before they were committed.

The only rules are:

1. No blaming.
2. No naming names.
3. State what the error was.

Examples:

1. Mag and KCl hanging without a pump. ---Both need to be administered on a pump.

2. Regular insulin, pulled up in mg's, not units ---Self-explanatory.

3. Digoxin 0.125 mg po qd ----Given with an apical HR of 42.

4. Order for Vistaril IV ---Never give Vistaril IV.

5. Lopressor 25 mg po bid, 1 tab ----Pt. got 50 mg. because this med only comes in 50 mg tabs and should've read "1/2 tab."

6. PRBCs hung over the 4 hour limit. PRBCs piggybacked into ABTs. ---PRBC total hang time may not exceed 4 hours. This might include time taken from the blood bank in some facilities. ---Never piggyback anything into PRBCs.

7. PRBCs not hung for over 24h with a Hgb of 6.8.

8. "Demerol 100 mg. IVP q2h prn" --Classic case of "too much, too soon."

9. "Percocet 1-2 tabs po q4h prn, Darvocet N-100 1-2 tabs po q4h prn, Tylenol ES gr. X q4-6 h prn" ---Tylenol can potentially exceed 4 gm/day max.

10. Dilantin piggybacked into D5. ---NS yes, D5 no.
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I would like your feedback on this issue.

[NursetillaTheHun]

IV med infused into a wound irrigation that was set up in an IVAC infusion pump. Luckily it was an antibiotic so did no harm (maybe even a benefit).

Lesson: Always follow line to source of infusion

Med error should be used as education. I like your idea NawlinsGirl. Keeps one humble and, hopefully, increase safe and cautious practice.

[3boyzmom]

Insulin given to wrong person in semi-private room. Nurse did call patient by name, but patient apparently didn't realize. Always have patient tell YOU their name. (and birthdate, in our facility). & look at nameband!

This was years ago. The nurse felt terrible- she couldn't understand why the patient answered to someone else's name. But, it's our responsibility to be sure of accuracy. Patient might be awakened from sleep; affected by meds; just plain confused, or in any number of altered states of attention or focus.

[NursetillaTheHun]

Ah 3boyamom I have seem the same thing happen.

I can't imagine how some extended care home deal with that situation where the patients do not wear nametags/wristbands. I had one friend start work at a Geriatric Alzheimers unit where they just had pictures up for patient verification. There were 12 similar looking grannies there! It took her 3 hours to give out the morning meds!

[aussie-margaret]

I took a man's sutures out after 1 day, once.

The Doctor had Parkinson's disease and had appalling writing - I could only read the R.O.S.
(the patient was there for a dressing and the dr had written R.O.S to be done in a week)

I asked the man if he was here to get his stitches out (to confirm the order because of the bad writing) and he said yes, so i took them out, then the man said "why did you take my stitches out - I only had them put in yesterday".

fortunately, was only 3 stitches and the wound was fine and did not open - just put some steristrips on and all was well.

Lesson: don't trust handwriting and don't trust a patient to confirm, even something simple.

very annoying that a patient doesn't query something that he knows is amiss, when I started to take the sutures out. Why just sit there and then query it after.

GLad it was minor and no ill effects

[NursetillaTheHun]

Aussie-Margaret:

I received a stern talking too when I follow an order to remove a foley. The patient had a stent so the catheter was ordered by the surgeon for it to not be removed for 2 weeks. The medicine doctor following the patient wrote the order to remove it after a week and a half. Oh shit hit the fan when the surgeon came by. I was told that I should have used my nursing assessment of the situation and have questioned the order. I am still learning the politics of which orders to follow, ah the joys of nursing.

[mattsmom]

Enteral meds intravenously instead of endogastric.

Infusion strength heparin on a pressure bags for arterial/PA lines.

Potassium IV replacement therapy given wide open vs sloooow drip.

Blood bank blood left laying on a counter for hours. Not really a 'med error' perse but an expensive mistake, and it was this nurse's last mistake on our staff, she was let go for it.

IV narcs ordered or given when PO or SC were intended, resulting in patient harm, contributed to by poor handwriting, inexperience of transcribing nurse, and inattention of doc and/or nurse. Lots of sad outcomes seen here over the years.

I'll think of more later. It is much easier today than in the past to make a mistake or a med error... due to the many systems we work under, and the hectic nature of our work areas. Just my opinion.

[3boyzmom]

Wow, this makes me tired just reading all this! Aussie-margaret- it never ceases to amaze me that patients don't ask until AFTER something has been done, right? My favorite is when you give a patient their meds, and they swallow them, and THEN they say "I've never seen that red one before." Once years ago I discovered like that that I had given a patient someone else's pill- that was way back in the late '70's, when you poured the meds from multidose bottles into little cups for the patients, that were on a styrofoam pill-cup-holder. All the patients' cups were pretty full, and apparently when I dropped a pill into someone's cup, it bounced and went into the next cup, and I only realized it when the person said "what was that blue pill I just took?" and then realized that the "blue pill" was not in the next cup that it was supposed to be in. I just about passed out. Fortunately no harm was done- and also fortunately every time after that when a patient has said "what was that blue one?" it happened that the meds were correct and I was able to easily explain to the patient what the "blue one" was. but it still amazes me that they don't ask until after!

And NurseTilla, we've all been there, right? One doctor complaining because you followed another doctor's orders. (did I miss the ESP class in school???)

[NursetillaTheHun]

hehe ESP! ah 3boyzmom I hear yah. I think every doctor should have to be a nurse as premed and work for a couple years before entering med school. I have a friend who in med school with a couple of nurses. She said they were amazing.

[ladybugj]

one of the most common mistakes we find in our hospital are iv fluid errors. either the stock area was incorrectly stocked and the nurse doesn't carefully read the bag or we get so comfortable in one of our most commonly ordered solution (D5.45NS with 20mEq KCL) we overlook the .9NS, .2NS, 10 of KCL, etc. and it may be missed for days. also, dextrose in a diabetic's fluid orders, tpn and il set at the opposite rate (now, 2 nurses must check the rates each shift), narcan gtt at wrong concentration counteracting morphine.

wow! i didn't realize once i started i could just keep going! thanks for getting the brain ticking!

[NursetillaTheHun]

ladybugj:

Good one! I remember one tutor/teacher I had and she said at the beginning of the shift, part of the head to toe assessment, is to follow the lines from the bag to the IV site. At first I thought it was just an extra waste of time but lately I have started to do that and I have caught mistakes or possible mistakes I almost made several times.

Any other tips?

[rottmommie]

atropine 3mg IV push.....
doc said .3mg, nurse gave 3mg. He died.

by the way, nowadays potassium and magnesium are to be on a pump....back then, you calculated the drip rate and there WERE no pumps. Of course they can't be given push! But you don't NEED a pump to give them.

Does Paramedic trying to intubate a decapitated person count?

[rottmommie]

atropine 3mg IV push.....
doc said .3mg, nurse gave 3mg. He died.

by the way, nowadays potassium and magnesium are to be on a pump....back then, you calculated the drip rate and there WERE no pumps. Of course they can't be given push! But you don't NEED a pump to give them.

Does Paramedic trying to intubate a decapitated person count?