code blog: tales of a nurse

Just a quick question on the Reopro - it's supposed to be mixed so that a bag lasts 12 hours. Did the doc write for a shorter infusion period? Did somebody mix the infusion incorrectly?

I give Reopro by the gallon (hey, we're a specialized interventional coronary care unit - go fig) and the administration is supposed to be really simple - mix, infuse 12 hours, stop when the bag's empty.

Well... see... uhhh.... Reopro is a 12 hour infusion, but I don't remember... it must have been mixed at
that hospital so that the bag lasted longer than 12. Because I called the pharmacy wondering where
my next bag was, and they told me that they never mix more than one bag of Reopro per person.
I was very confused and asked another nurse, who informed me that Reopro only lasts for a certain
amount of time.

I was a new nurse and although had infused R before, must not have had to pay attention to the stop
time (as in, the other exposure I had to Reopro was when a patient came from CCL at 5pm with it infusing, and I went home at 7pm). I just wasn't paying attention. It ended up infusing for about 2-3 hours
longer than it should have. (I called pharmacy when it only had the tiniest amount left, thinking
that they would have sent me another bag already!)

The Institute of Medicine, when it issued its report about making our country's health system safer in 1999, focused on medication errors as one of these areas where physicians and other caregivers like nurses need to do better. In fact, most state medical boards now require physicians to take up a two-hour course on the prevention of medical errors as a condition for relicensure.

As far as medication errors, steps have been taken to modernize the system of delivering medications to prevent the sort of errors, which are minor, which you cited in your story. Finger-pointing at individuals, whether doctors or nurses, ought to be shunned in favor of correcting these mistakes on the basis of a systems approach. The systems approach is what made anesthesiology and our aviation industry so safe today.

I have also felt that nurses ought to have more education, along with continuing medical courses (CME), in pharmacology. Knowledgeable nurses are the best partners of physicians, particularly in the hospital setting.

By the way, you ought not to feel bad for your errors. They were minor and we need to learn from them. Dr. Atul Gawande wrote in his best-selling book, COMPLICATIONS, that while perfection is impossible, it is not unreasonable to try to aim for it as best as we can.

R.G., I don't know about what's required at other hospitals, but where I work, we have ongoing CEUs, many of which involved pharmacology and dosage calculations. Not only that, we have to test out and be recertified every year as part of our evaluation process.

Even with those things, medication errors still occur. Poor charting habits, not having uniform charting procedures for all departments (this mainly refers to the ED, OR, and PACU,) and frequent changes in orders that are not caught, all contribute to the confusion.

Med errors are mortifying. I'm ultra-cautious with the meds I give to my patients because, frankly, I'm terrified of making a mistake that could result in complications for one of the kids. Not only do I follow 3 (I do 5) check method, I also follow the 5 (6) rights of administration. Better safe than sorry.

Da Goddess, that is what every hospital should be doing, but I'm not sure that is standard procedure for many that I know of.
I also admire your conscientiousness and concern about not making mistakes. That is something every nurse should adopt in taking care of patients.

I recall that two years ago, recommendations were issued by a joint team from Stanford and UC-San Francisco regarding the "best practices" felt to miniminze or eliminate medical errors, including the subject of medications. These were published in 2001 in an issue of the JAMA.

Keep up your excellent work, DG.

seriously, you are concerned about Lasix?? In my insitition we would not even informed the doc.

Seriously, you don't inform your doctors of med errors?

The RR RN gave 80 of Lasix. I gave another 80. That's double the dose for a patient that is post-op, and quadruple the "normal" dose. Even if it had been just 40, or even 20, I would have let him know. What if 160mg gave a specific response, and the MD thought that 80mg was responsible?

Lasix isn't exactly a Flinstone vitamin, ya know.

I just transferred to a small rehab/acute care facility. I had always had trouble remembering to sign off the mar's, and today (census went low) and I was fortunate to have the rest of the day off...I forgot to sign the mar's.

My supervisor was so nice about it. Fortunately before I left, I told the nurses I reported to that I gave all meds up to noon (when I left).

As this is a small facility, we have one on staff pharmacist. She said that guidelines indicate that each med I didn't sign off constituted a med error and not only was I in trouble but it would raise her error rate. I felt like such a fool! I have been a nurse for 8 years in the acute care setting and I had never done something this stupid. At other facilities, they would call and ask if you gave the med, and have you sign it when you came in the next day. It isn't this way at this small facility.

My supervisor (who I have worked with at another facility for years), didn't write me up (thank GOD), but he did say that "if I didn't know you, at a 50% error rate, I would have to let you go."

That last comment was an eye opener.
I felt so stupid and incompitent. I have always been "the nurse" that everyone would come to with questions, concerns, hard IV starts.
I've been a house supervisor, charge
nurse, etc.

I appreciated them being so kind to me and I made it clear that I didn't intend to make their job difficult.
I am taking 2 days off from another job to get my head together. They said that they could tell how upset I was and that I could do better.

I just felt like such an idiot.

Thank you for having this website so I could vent.

linda

I was put into a detox without being drunk or on drugs. I was at best a moderate drinker.

Someone helped explained to me why this happened. Like sometimes people who work in a specific profession they become overly focused on, like in my case, how alcohol affects the brain, even in small quantities.

I stumbled into this place thinking I was going to kick my issues with depression and abuse.
I was hoping for coping skills. Instead I had a warped experience in denial.

The admitting nurse was strange. She asked me how much I had to drink in the past 5 weeks. When I said I drank every other day, when I visited my parents, she got this look of disgust even though, I mentioned I only drank 1 or 2 drinks at a time (ie beer, a glass of wine with dinner). I then told her I drank 5 beers at a party two weeks earlier this look of disgust washed over her and she whipped out these forms, and had me sign them. I refused to sign them at first asking why the hell she had me sign up for a detox? She said oh everyone has to sign these forms. So I signed them. I asked her where I was going, she said why do you think you're here. I said that I had a bad experience 8 months prior that was causing me problems with sleeping and depression. The problem involved an incident at a party. I was drinking. I can't say I was hammered. I have full memory of everything that happened. The nurse shook her head and lead me off to the detox, even though I still didn't even have an idea where I was.

I was given a "sleeping pill" by a nurse the first night I was there. I clued in I was in a detox, when the nurse came up and gave me a vitamin B tablet and a diuretic to "wash out the alcohol". When I sat up and said I hadn't been drinking she said oh your reeking of alcohol. She then came back with this sleeping pill and insisted I take it, and not spit it out.

If you have had the odd drunken moment in life I am not of the belief that you should be shoved into treatment. The odd drunken experience being rare and easily recallable.

The nurses insisted I was a stinking alkie the whole time I was there. They commented on how drunk I was. I told them it was impossible, and they might as well insist I am diabetic instead.I drank two Zimas with a friend at a party 3 days prior to entering the clinic. They insisted I drank very heavily nearly everyday in the prior 5 weeks, and I was having black outs where I was having none, and hearing voices without me verifying I was. They insisted I was drinking fairly regularly in the prior 8 months as well. I maybe only had 4 drinks a month. They called this heavy drinking.

Disgustingly my charts also try to say I took benzodiazepine, as of no consequence of them giving it to me! I am not a pill popper. I had never taken anything like that before in my life.I guess because they couldn't find alcohol in my system they insisted that I must've took something.

I feel my experience is a bunch of doctors and nurses insisting they're right, without respecting or listening to the patient. I think the benzodiazepine wound on my charts because they were so blindly sure I had something in my system, that they couldn't beleive they were wrong. this was a $7000 a night facility! I guess they had a reputation at stake.

I don't care what title you wear LPN, DR... If you don't listen to your patients, you might as well quit. Patients know themselves best, so listen. Yeah my case is weird but people do get lost in the system with illnesses that could've been easily diagnosed and treated.

This treatment has caused horrible psychological damage and has made me incredibly angry at the "caring" profession.

Another thing to bear in mind is effective patient monitoring before and after release. One patient, having suffered myocardial infarct, was released while undergoing a regime of Warfarin. His INR hadn't been monitored for four days before release. The staff had just been overwhelmed with work.
Two days after release, he was re-admitted. His INR was 11.5, with all the associated consequences. He died three days later.
So please, please, make sure that this particular mistake doesn't happen again. Others will - for those in the medical profession are only human. But the patient was my Father, and I still miss him.

I am still in shock! I just found out that the fl dept of health is
putting me on probation for a year.
I erroneously gave too much insulin to a pt. The pt was taken to the hosp. and was ultimately ok
I have been a nurse since 1982 with no problems ever! I am ready to relinquish my license. I know I made an error, but I am an agency nurse, with an excellent reputation
in this community and will not be able to work with the restrictions now put on me. Such as having to have another nurse mentoring. I have pretty much just lost my career. I did not have any legal rep. but I didn't realize that I would need it, and I also coldn't afford a lawyer to fight the same agency that licenses me.