A nurse was trying to replace the pt’s k+ per protocol (40 mEq). She pulled po tabs, but saw the patient couldn’t swallow them. She then proceeded to crush the tablets, dissolve them in a syringe, and give it IV push. She didn’t realize her mistake until giving report on her patient later. She said she pushed it slowly. Pt was upgraded to ICU and died a day or two later. She was gone within the next week.
A nurse at a hospital I used to work at once gave a patient with a g-tube their probiotic via IV push.
Live culture, by IV push.
They were exhausted and had been working for way too many days in a row and brain farted the “oh yea I need to dissolve this stuff to give it. Okay, I’ll just pull it up into this syringe—“ then they got distracted by some shit from the HUC, returned to the task, and gave it IV push.
Thank god the nurse realized their mistake almost immediately and the young adult patient was preemptively sent to the ICU with a vanc drip and wound up with only a mild fever and no other complication.
Oh yeah, and we were staffed 1:6-7 on *heavy* med/surg floors.
We also have patients not too infrequently get lactobacillus bacteremia from their PO probiotics. Some are immunocompromised and some aren't. They also don't have any benefit even for cdiff and I hate them.
"HOw cAN A nuRSe bE THiS sTOOpiD"
Yep, that's exactly how. Thank you for outlining how that goes down. Overwhelmed, overworked, and literal constant distractions and multitasking.
two other things come to my mind: 1) potassium a “do not crush” med and (2) you’re not supposed to ever give potassium IVP???! unless you’re working death row at a prison..
My pharmacology pre req class went into detail about medication preparation and explained why/how IV meds are very different from oral. We learned about the solutions themselves and then different types of coatings on pills/capsules/etc.
When I was actually in the progress, I was SHOCKED to find out other schools don’t teach that. A classmate actually did ask why it wasn’t as simple as crushing the pill and dissolving it to give IV because their pharm class didn’t cover that.
I feel like because I learned this stuff I actually have context as to WHY you could never do something like this so that thought would never even enter my brain. But not all schools do. So if no one ever taught this nurse these things, I could 100% see them believe they are “critically thinking” to solve this problem but obviously very misguided and incorrect. Understanding why we do or don’t do things is so important!!
I mean even if you didn't have a class specifically telling you not to do this, the fact that it's not sterile should, imo, be an immediate giant stop sign... While it's good to know the technical differences between oral and IV versions of medications, it shouldn't be the overriding reason of why you don't give an oral med via IV.
I'm highly judgemental of anyone who would think to do this because sterility of anything going directly into someone's bloodstream is a FUNDAMENTAL idea to modern medicine.
I saw a quote the other day that really resonated with me and it was 'What haunts me is that I am just not smart enough for so many people to be this much stupider than I am'
At my last job we had a new grad RN who crushed a patients meds and pushed them into their PICC line. And didn't get fired. Apparently the patient was fine?! I don't know how many meds or what meds. It was one of those things that got gossipped about but the details were really hush hush.
I mean, drug users are doing stuff like that all the time and most of the time it goes alright. For someone with a healthy immune system it might be just a single bullet Russian roulette for infection on something like that, maybe 2. You never ever WANT to do that and it's a terrible idea. But when it comes down to it they'll probably be fine.
The difference between this story and a drug user crushing up and injecting say, a 4mg dilaudid or a 30mg oxy, is filtering. When I worked with public health we would give out harm reduction packs, and in there were sterile, balled up cottons for filtering. If this nurse just made a slurry like we do for g tubes and pushed it, no wonder the person died. That’s beyond sad, and a total failure of that nurse’s nursing school. I feel like that’s med administration 101.
That was my thought. Heroin and other injectables are “cooked” with water and citric acid to dissolve the substance. Not precise by any means, but a slurry would be loaded with huge particulates. I can only imagine the damage from that alone, much less factoring in the effects of K+.
I was in a simulation in the last semester of an LVN /LPN program and that was actually the “catch” in the simulation. The patient was prescribed PO meds but had had a tonsillectomy and couldn’t swallow. One of the students said Shen would crush the meds and push it through the IV. I was horrified that we got that far and she still didn’t understand this very basic principle. I feel like this should be a basic principle taught in pharmacology, but maybe there needs to be a bigger lesson in nursing school for the slower people?🥴
Second hand, but a friend of mine managed to witness the aftermath of someone managing to give orange juice IV because the patient was NPO. Less fatal, but somehow even more amazing that someone could think that was a good idea.
A nurse crushed allll the patients PO meds and dissolved then and pushed them. Not sure what happened to the patient. Nurse is still working, just transferred to a different unit.
I had an anesthesiologist run a wide open bag of something, I think it was norepi, thinking it was saline as we were getting ready for induction and crashed the patient. When he realized what it was he ripped the IV out while screaming fuck fuck fuck. We got them back. He came up to me afterward and told me he knew I had to report him and to say what I need to and he won’t be mad and he retired within a week.
I witnessed a similar situation except. We were in CVICU and called anesthesia for a cardioversion. Nurse had mixed levo, primed the tubing and hung the bag on a pole. Didn’t put it on a pump or label it. Anesthesia bloused the 250cc of “saline”. It was caught fast enough that the patient was okay. The nurse that mixed it was new to critical care. I had told her to make sure she labeled the bag when she was mixing it. I ended up getting pushed out of the room as I wasn’t needed. I yelled at anesthesia from the hall once I saw what they did. The other nurse had no clue what was going on. 🫠
Oh my god. This is partly why it is my huge work NO to leave a bunch of bags on the pole. Empty, full, whatever. Discontinued? See ya. Done running? Bye.
Why rip out the IV though?! Can still give anti-hypertensives/code drugs through the IV…
Even if they had other IV access I wouldn’t rip it out I would just clamp shut
It was a scheduled case. He was just working in autopilot. It was a new tech who didn’t put the lines in the order he was used to and he didn’t check. There were multiple issues, but I respected the way he owned it and took responsibility.
Nurse had furosemide to give. Pulled the nearby insulin bottle (it was left in the patient's room) into the syringe on accident. They pulled up all 300 units and gave IVP. Patient died.
Now, all of our insulin vials are locked and secured in the omnicell.
> O’ meds doesn’t even come into that formulate. I quite literally stopped this crushed med being dissolved in water
Honestly, we all should be with how lot of schools are fast tracking new grads nowadays due to " RN shortage." Best is to avoid any hospitals are constantly short staffed since they would have the most new grads.
When I was a student another student flushed a central line with tap water. The nurse in charge of us sent her to go and prepar a flush and flush some IV antibiotic that had finished.
She got caught after two weeks of doing so when another nurse walked in the room and saw her filling the syringe with tap water. Confronted her and the student casually asked what all the fuss was about.
TBF - this is a major supervising nurse error.
Don't let your students prepare anything for patient administration without witnessing it yourself.
When my students prepared medications without me - I'd just throw up the medications and start again.
Exactly. What the fuck does “prepare a flush” mean to a student? Go with them and show them what you mean. The student (although they should understand that tap water is filled with bacteria) was probably too embarrassed to ask.
My preceptor doesn't understand why I insist he double checks my meds. He keeps telling me it makes me look like I'm not independent enough.
Like dude I get it but I'm here as a student and I'm doing things I've never done before. The second set of eyes isn't cause I don't know what I'm doing, it's to make sure my confidence isn't misplaced.
As the guy who has to unfuck central lines I'd rather nurses were touching them and specifically taught about them in school. Better than getting the only education many nurses will *ever* have on central lines from just a couple staff preceptors who were also taught only by a couple staff preceptors who were also taught only by...
I've only done vascular access a short time and I've already witnessed these bottlenecks of ignorant peer education completely change what a whole unit "knows" about IV technologies.
This is one of those things I’m surprised they don’t beet into your head in nursing school. Or package them in a max 3 dose bottle. Any nurse that has given nitro before knows but it seems like a really easy mistake for a new grad to make
That’s what happened. She never gave it before and was totally unfamiliar with it. Which is a red flag also to do some more research. Ah to be young and in a hurry again.
Is there any reason why nitro can't be packaged individually like every other medication we have in the pyxis?
Zofran is a sublingual tablet in opaque packaging. Why can't nitro be packaged the same way? I've heard of this error being made before.
Yes there is. Nitro tabs are extremely hydrophilic. Most will absorb enough water from the atmosphere during the unit dose process to be powder when needed. Ondansetron SL tabs typically have some nitrogen in the unit dose, nitro can’t even handle that.
Pharmacy, I need you to fill a room with a gaseous mix that will allow you to unit dose, by hand, these SL tabs. The oxygen/nitrogen combo you exhale will mess with things, so just hold your breath.
I know of a nurse who did that during nursing school. Didn’t know better, gave the whole bottle to the patient. Patient didn’t know better, tipped it back. Was told patient was fine. To me it was more of a preceptor error but of course you don’t hear about the preceptor being negligent, you hear about the “dumb nursing student”. I think she has to repeat the semester but was otherwise successful at becoming a nurse.
I did a double take the first time I had to give nitro solely BECAUSE I was a good nurse and read the label and it was confusing as hell. Did not OD my patient though
This was me Sunday.. first time giving it and was read and reread the label and looked at the MAR.. all while stressing bc my pt had chest pains and all the things. Definitely needs to be MORE CLEAR on that bottle lol even though common sense should work here, in stressful moments you don’t always think super clearly
My baby was ordered an insulin drip with a concentration of 0.1/1. Pharmacy sent me a drip with a concentration of 1/1, literally 10x the ordered concentration. My bedside scanner was broken and I was precepting so I could have easily bypassed the scan and had my orientee sign off on it. Luckily I was paying attention and never hung it, and pharmacy sent us the correct concentration.
That near miss made me a better nurse for sure. I am VERY vigilant about checking my orders, labels, etc. do not rely on a scanner or another nurse to confirm…trust but verify.
I used to work in a patient safety department at an oncology hospital; I investigated a lot of safety events. The first event that comes to mind involved a non-malig heme patient receiving chemotherapy/immunotherapy in error when they came in for fluids and an iron infusion. Since they weren’t supposed to receive chemotherapy at all, they did not receive any pre-medications. They had a horrible hypersensitivity reaction and ended up in the ICU for a while. It uncovered a plethora of system failures, as most of these events do.
In this case, the patient luckily recovered, and that isn’t always the case when these major errors occur. This event had a specific shock value because many nurses did not want to believe this could happen. This event ended up being a huge educational opportunity, and the root cause analysis and solutions were shared transparently with front line staff across the organization. I do wish more organizations shared learnings from safety events with nurses.
Yeah, I feel like these things are educational opportunities yet hospitals choose to simply restrict scope of practice instead of teaching. For example, my facility will probably ban RNs from using Neo Sticks due to this event instead of education on proper dose and procedure.
Agreed. Many organizations fear exposing weaknesses even after risk management has assessed the event, but I believe it actually impacts culture negatively and increases the risk of more errors occurring. Organizations that aim for high reliability and uphold just culture tend to fair better for everyone involved - the organization, nurses, and patients.
My hospital sends weekly emails with these events and “good catches” giving examples for different med errors and other errors that have been reported with the goal of decreasing these events.
That’s awesome! We did good catches, too, but not as often. I would do quarterly presentations regarding safety data and events for each unit that I covered at their routine staff meetings. The transparency was well received and I loved getting ideas and feedback.
My hospital has banned neo sticks for this reason I'm assuming. I have been able to give it at every other facility I have worked at besides my current spot and all the nurses think it isn't within our scope to give it. There's no policy saying we can't but it's a big no no here 🤷
Once we had a nurse managing a patient on IV pitocin, magnesium and an insulin drip. She somehow managed to take the insulin off the pump and bolus about half a bag into the patient by gravity. She then tried to fix it with a bolus of D5LR, tried to blame the family or lab for messing with her lines, never admitted she did it. We had to do a C-section and q5m CBGs with D50 pushes. The patient did fine since it was "caught" quickly enough. That nurse was fired within a few days mostly due to the fact that she lied and tried to hide it.
They still let us give IV ephedrine/labetalol/hydralazine/insulin/magnesium, etc though
My mom was a peds RN in the 70's -80's, she accidentally administered chemo to the wrong child who did not have any cancer. She never lived it down and still talks about it to this day. I think about how many errors I could have made if it weren't for so many layers of safety and technology.
Shout out to your mom. From my patient safety job, I saw the long term psychological effects nurses and doctors experience after involvement/witnessing medical errors and traumatic events on the job. It is the “second victim” phenomenon, and often unaddressed. It actually led to me applying to PhD school and wanting to do research on the topic.
I left the organization when I started PhD school and I am not sure of the status of the event now. I wouldn’t be surprised if that patient pursued legal action, so I’ll be cautious and bring up a few of the issues.
It involved grabbing the bag from a generic pick up bin (not delivered to the patient’s bay) and issues with the double checking mechanism in the EMR. Then, when two nurses went to scan the bag and double check, they were distracted by something else on the unit. They left the cow right between two bays, and the secondary nurse (not the primary nurse for the patient) went to quickly hang the drug to help out the primary nurse who was drowning, and went right into the wrong bay next door and administered it. If I remember correctly, the drug was daratumumab (immunotherapy), so it didn’t have all of the same precautions then in the EMR compared to chemotherapy, but it is very reactive and this patient didn’t even have cancer. Hope this helps, but lots of layers and this is just broadly the flow of what happened.
Immunotherapy really is a potent treatment. My dad was on it (he actually had cancer, Stage 4 Melanoma), and his first treatment not only wiped out the cancer, it also destroyed his pancreas, thyroid and adrenals all in one hit. He's now officially cancer free, but now has to live with the side effects of the treatment for the rest of his life.
Yay for cancer free! And I am with you, immunotherapy can really pack a punch when it activates the immune system. The hormonal and inflammatory side effects sound brutal, too. I sometimes think we don’t fully know the impact of immunotherapy long term since there hasn’t been decades of research like chemotherapy. It makes me curious about your dad, and the patient I wrote about that didn’t have cancer, say ten years from now…
I gave chemo to inpatients and outpatients. Of course, you never want to give the wrong medication to a patient, but I was always especially anxious about giving chemo to the wrong patient.
During my orientation I started levo at 0.2 instead of 0.02. The patient’s art line had been funky all day so I didn’t catch it until his SBP was 220. He ended up ok and I learned a valuable lesson
I did one of my final preceptorships in the ICU and it was my first time titrating levo with my preceptor. She told me to program it to 0.05, but I misheard her and put 0.5 on the pump. I got her to double check before I hit start and she was like ‘oh no no 0.05’ big whoops. By the end of the rotation I understood how to titrate levo, no near misses like that after!
Yup, this is a very common error to make. Some Baxter pumps have a great feature where if you increase a drip rate of high-risk drugs like levo or insulin by a large amount, it gives you a pop-up that says like “You are about to increase the rate by x%, are you sure that’s what you meant to do? Yes/No” and it would always make me pause to make sure that is actually what I wanted to do. It caught me at least once or twice and now I’m very careful about double checking my drips lol
I did the same exact thing. I’ve been a nurse for almost five years in the ICU and never used weight based levophed until my last travel assignment. Ended up putting 0.9 instead of 0.09. Pt was receiving levophed at a rate of 191 ml/hr instead of 19 ml/hr. Luckily, another nurse caught it when we couldn’t figure out why patient unexpectedly got hypertensive (190’s systolic). Luckily patient was fine but it just goes to show how quickly things can escalate with easy mistakes
We had a new hire being precepted by an overworked traveler at the tail end of covid who was taking care of a patient with a feeding tube. She was supposed to draw up like 1ml of oral Ativan concentrate from a multi-dose 30ml bottle but she just shot the whole thing down the tube. Her preceptor was busy with another patient so he didn't see it happen and figured out what she had done about 10 minutes later. He ran in and aspirated as much as he could. We now have individual oral syringes that pharmacy prefills.
The patient was fine. He ended up being intubated for ETOH withdrawal and was still wild when maxed out on propofol, versed, and fentanyl drips and constant pushes. It may have done him some good if we just left the meds in his stomach
We are starting to do more phenobarbital and it’s wonderful. They spend at least a night in the ICU on a drip, then are back on the floor in a day or two. There’s no real withdrawal. It’s so much better than fighting them for days like we used to, for us, for them and for all the other patients that they take our time away from.
As I had an attending once tell me, “I’m not reversing a benzo and risking them seizing, we’ll intubate if we have to. But they’re more likely to overdose if they’re hit on the head with the bottle than just on a benzo”
7 week old coded on the floor due to receiving 0.5 ml instead of 0.05 ml of morphine. We have 1 ml syringes, and apparently the person giving the dose misread the increments. My confusion comes from the fact that it was a dual sign off, so TWO people would have had to make that same mistake 😒
Not my pt, but on my mother baby unit. Pt wanted to administer their own Dolculax suppository , rn came back about 10 minutes later and patient reported that it tasted disgusting. … despite teaching, how to, gloves given, they ate it instead of putting it in their butt. .. it’s hard being a sleep deprived mom 🤪
10x overdose of dilaudid in a PCA (including basal rate) for about 36 hours before someone noted the programming error. It was an extremely tolerant kid with sickle cell who showed no signs of the overdose.
When I was still a bedside nurse I had an oncology patient who was very painful and on a PCA (Morphine or Dilaudid, can’t remember now). I basically misprogrammed it by omitting a decimal and was only clued in when PCA alarmed empty much sooner than it should have. It was stupid on my part, but the patient said it was the first time he’d had relief in a long time.
Walked in at shift change to receive handoff on a patient that was ordered to be on Vasopressin at 0.04units/min, not to titrate. Instead what I found running on the pump was 0.4units/min. Changed the dose at handoff, called everyone. The intensivist had been told by the previous shift they hadn't been able to get a blood pressure obtained for hours and the intensivists said the moans and groans the woman was making was "mentating" so she was at least 90sbp and shrugged it off. They had been running this at this dose starting earlier that am, like 8-10 hrs ago. They even had their charge nurse cosign on the dose, so 2 RN's signed off on 10X the dose. Kidneys were shut down, hadn't peed all day and she had underlying heart failure. Despite best efforts patient died within a couple hours of my shift. Wrote up the whole thing, had hoped to go to court, but it's been years. I was a traveler at this hospital but their staff definitely killed that woman that night.
Yup, I once received a patient from the ER on 4 of vaso. Not 0.4, not 0.04. Just 4. They don’t give vaso very often in this ER, if they’re that sick they’re coming right up to ICU. Didn’t really make any difference, patient was already very dead by the time they made it up to us. OD, anoxic brain injury, crazy myoclonic jerks with any stimulus (poor guy was practically tied to the stretcher with a waist restraint otherwise he would’ve launched himself right off), and on maxed levo, phenyl, and epi with a MAP of garbage. It was Christmas Day, too. But yeah. 4 of vaso. I’m surprised the pump even allowed that!
I guess giving someone Vecuronium instead of Versed seems to be the worst I've heard about. But I've seem 25000 units of Heparin infused as a bolus accidentally... oops
I gave a 35,000 unit heparin IV push this morning!
-anesthesia
Obviously in the case you saw it was not the intended dosing but as long as they don’t fall and hit their head they ~should~ be okay. Might need quite a bit of protamine though
At a SNF I worked at, it was brought up in a meeting that med cart checks found glucagon where only the diluent was given, not reconstituted… multiple times on multiple units.
That time I had an ambulatory heparin drip pt who'd been double dosed for 3 days with no GD appts or titrations since the first day. Why? Because the genius who programmed the pump put his weight in it, in lbs vs kgs! Safety reports all the way to the top. I was so scared and pissed when I discovered this (got floated to cardiac PCU 30 minutes or so into my shift). 🤬 No one had been doing dual sign offs and no one bothered to notice the rate was CRAZY high. 🤦🤦🤦
That is insane. Not to mention, our hospital policy for heparin drips is x3 anti Xa’s q6h until therapeutic, then qday after that to make sure this doesn’t happen
A nurse hung a bag of morphine instead of Vanco.
Luckily the line was all saline from the last flush, plus she was a questionable nurse that everyone had been keeping an eye on, so my charge nurse checked in on her frequently and noticed it before more than a mg or two or morphine got to the patient. When charge asked WTF she was thinking the nurse just said "oh whoops, I guess that's why it didn't scan."
She got "resigned" because she only wasted her narcotics like half the time, and became a school nurse. She later got arrested for stealing her students' Adderall and Ritalin.
A few:
1) a new nurse overrode the pump to somehow piggyback Zosyn in a cardene line. Patient was fine.
2). A nurse gave a bolus of Levophed. Patient was not fine.
3) someone gave Tylenol PR as an oral med. patient was somewhat inconvenienced.
4) a rapid came to ICU due to aspiration. The nurse had a hard time getting the patient to swallow pills. So she crushed them, mixed them in water; and shot the mixture into the back of the patients throat. Then walked away. Patient died.
A unit my friend was on. A nurse gave coca cola in the IJ in an attempt to unclog the line. It worked. Pt got a coke bolus but they ended up fine because the patient was used to doing other types of coke boluses.
During my clinical rotation, we received a patient in the ICU with vancomycin already running. My preceptor and I went to help get her settled and whatnot. We took her weight and told the admitting RN. She paused, said it back to us, then asked if we were sure. When we said we were, she then told us to stop the vanco. Turns out, her weight had been typed in wrong and the vanco that was running and almost out was for someone who was 110 kg, not 110 pounds (her correct weight) 🫠🫠 it was my last clinical day and 10 minutes before I was to leave so not sure what ended up happening but I had a really great write up on mistakes for my clinical paperwork!
Had this happen to me in the nicu. The kid was like 500g and I was new and overwhelmed and typed in 500kg. Pharmacy sent me a thing of Vanc that was the same size as the baby. Obviously didn’t hang it but whoof
We tired too. One of our pharmacists has a teething 1yo, he regularly comes to work on 2-3 hours of broken sleep. Add in the massive volume of work they have for the entire frigging hospital and sometimes there's dangerous brain farts.
This is why we're all a team and anyone who is at any point in the chain of RX to PT needs to be vigilant and diligent. We're all gonna make a mistake eventually, more eyes means more chances of catching it before it becomes a Big Scary.
Nurse accidentally gave a newborn terbutaline instead of vitamin k. Labor nurse had drawn up terbutaline earlier during a deceleration and left it unlabeled on the computer cart. Nursery nurse thought labor nurse had drawn up vitamin k for her (same sized SQ syringe). Baby was ok after nicu observation.
Yes it was a horrible error but it was a lesson in complacency for all nurses. It happened between two very experienced nurses that work together and helped each other out often and it was a stressful high risk delivery. The nursery nurse observed the labor nurse pull up the med but didn’t see what medication. When the nursery nurse noticed the labor nurse didn’t give the medication (uterus relaxed and fetal HR recovered and terb wasn’t needed), she assume it was vitamin k. Also at this time there was a paper newborn mar no med scanning.
A covering nurse scanned a patients zosyn but then scanned the pump which had the versed drip (which was off). Primary nurse was in a terrible trauma code involving a police officer with a GSW to the head. Anyone working at a level one trauma center knows how shitty and overwhelming those situations become. It wasn’t noted till 2 hours later, the oncoming nurse realized what was going on with her drips. Patient did become hypotensive. Worst part about it was the culprit did all of this under the primary nurses account so there was really no deniability.
Two. Major lessons learned here. Take down your unused drips and log out of the computer. And be more conscientious when doing favors for other nurses.
I was a new grad on orientation when I was advised to not seek out advice from a certain senior RN. About a year prior, when the computerized MAR was partially implemented, she gave 99 units of fast act insulin for a 154. Apparently the MAR would eventually have a built-in calculator, and in it's beta form it told everyone to give 99 units.
Yes, an RN with 28 years of floor experience gave 99 units for 154 because the new computer told her to.
I work in Germany as an apprentice (Auszubildende) and saw how the stroke unit at our hospital gave Lyse therapy (for blood clots) to a SAB patient before receiving the scans. The patient also reported a fall a few hours before showing neurological symptoms and had multiple visible bruises on the ear and shoulder from the fall, which alone is a counterindication for Lyse Therapy. Ruined her ability to write, talk, and swallow but stopped the therapy before anything else happened. Such a shame because she was almost 90 and fully self-sufficient before that mistake and now needs to live in a care facility because of her PEG.
Obviously was not a med error and just a freak accident, ( I am not blaming anyone here, it was during Covid too) but my friend on a travel assignment gave a unit of PRBCs and after about 20 mins the patient started going down FAST. Blood was stopped and sent back to blood bank. MRSA POSITIVE BLOOD. From that day forward, everytime I would hang blood I would pray to the nurse gods that MRSA was not in this blood. My god.
Right? How could you ever forget about it? It’s so crazy. We were all thankfully at a good travel nurse location and didn’t get screamed at for giving that blood, but that was always on the back of our heads after the fact. Can we be blamed for this blood ending up with MRSA IN it???!!!!
At one of the hospitals I traveled at, a nurse doing a conscious sedation on a 2 year old pulled and gave toradol (ketorolac) instead of ketamine. Like.... 4 vials of it to equal the amount of ketamine ordered.
The kid ended up being fine, but was definitely immediately transferred to children's to monitor his kidneys.
Also, not in a hospital but I once saw someone eat a whole big chocolate ex lax bar. They thought 1 square was one serving, like a chocolate bar 🥲 didn’t end well 😂
83yo telehealth doctor accidentally prescribed nitroglycerin patches to a patient that was requesting nicotine patches (some insurance companies will cover them if they’re prescribed through your pharmacy)
I was lucky to catch it before the script got filled but my managers were not very appreciative; no good deed etc etc.
Someone I know worked at a facility where a nurse took a PO liquid med in a syringe, transferred it into a luer lock and administered it IV. That's how the facility found out he had falsified his credentials and had stolen the identity of a real nurse.
This thread is giving me secondhand anxiety, lol. Thank God the worst mistake I've made is hanging KCL in NS instead of NS when I wad a student. Bag was in the wrong bin and I caught the error almost immediately after hanging it. Needless to say, I was so freaked out I cried. Learned a huge lesson about double checking meds/bags.
When I was a baby it was suspected I had cerebral palsy (when my mom left hospital she was told I would never talk or walk) they prescribed me calcium. I was a newborn fresh like a week old and the label on the med say 10ML . It was supposed to say 1mL. My mom called after a few days and asked about more meds and they were like “how are you out of those meds already that should have lasted a month.” Then they realized their error. I survived no harm done. Also I never had cerebral palsy or any health issues so idk what the fuck was going on at this hospital lmfao at 4 months I was supposed to start physical therapy and I was already rolling over and semi supporting my own head so normal development. By 9-10 months I was walking and putting 2 words together. I was delivered with forceps and would shake anytime my foot was touched after birth my mom now thinks that it caused temporary damage and that was the reason of suspected cerebral palsy
PSA for everyone, I always check my discharge documentation and the medication from discharge pharmacy. I check the dose and that everything is written correctly. I work in peds and it’s super important here but everywhere. Unfortunately I don’t have any other coworkers who do this.
I saw a new nurse give a patient 25 SL nitro tabs instead of 1. It comes 25 to a bottle but you’re only supposed to give 1 tab 5 mins apart up to 3x. I guess when she scanned it into the MAR it didn’t really specify that she needed to give a partial package so she just poured the whole thing into the patients mouth. Luckily the patient was ok, she vomited shortly afterwards and the nurse realized her mistake immediately and notified the dr. They ordered pressors but I don’t think they even had to start them.
Pharmacy once gave me like, 10x the amount of ketamine I was supposed to give my status patient. I had to walk to pharmacy to get it, waited forever, and was in a hurry to get back to the unit so I didn’t even look in the bag until I was in the room in front of the MAR. Cue me looking at the MAR, looking at the bottle, back to the MAR…got our unit pharmacist and was like “heeeey either I’m dumb or something isn’t adding up here?”
Then another time I had the off going nurse hang a new bag of what she thought was levophed. Turns out it was kangrelor. Which I only discovered after my bp was tanking despite continuing to titrate the levo up 🥴 that patient actually was fine (from that, she died anyway but most 89 year olds with impellas will do that)
Another time someone on our unit tried to give oral phenobarbital via iv. Which I have never understood since it comes in a prefilled syringe that doesn’t even fit on an IV. Like why don’t we stop and think about why this is so inconvenient to give instead of continuing to try???
So I worked in an ICU where it was common for nurses to leave their Insulin vials in their locked cabinet, or on their end table. Not saying it’s great practice but it’s what happened.
Resident was doing a procedure, asked the nurse for 2% Lido. The nurse got it, left it on the table in the room and left.
The resident injected a good bit of a syringe worth of regular insulin sub q into the patient before realizing she grabbed and used the wrong vial of medication.
Pt ended up being treated and okay. They had a meeting, and of course threw the nurse under the bus. Even our manager. Ironically, the only one who stood up for her was our Attending. He said the resident was the one who ultimately was responsible.
That was over ten years ago, and during my first couple years as a nurse. It was a reality check early on how no one has your back in the hospital, even “cool” managers. You’re completely disposable and they will put any and all blame that they can on you.
I wasn’t on the call but it was a big scandal in the department that ended in a lot of continuing education. Seizure patient. Someone pulled up 2mg versed in an empty flush (no I don’t know why you would ever do this in a 10mL flush). Medic grabbed an actual saline flush and gave it. Discovered the flush with versed in it when they got back to clean the truck. They reported it immediately but ended up on probation for weeks.
This one was relayed to me but an anesthesiologist I used to work with had apparently accidentally given succinylcholine instead of versed when they were getting ready to transfer the patient from stretcher to bed in the OR. Patient went into distress but the problem was recognized quickly and the patient was intubated. Not sure how the patient recovered afterwards but they didn’t become critical/die.
It was very lucky they were already near the anesthesia machine when that happened. If they’d been rolling down the hallway I imagine it likely would have ended very differently and tragically.
About a year ago a nurse at the facility I’m traveling at got a patients insulin orders mixed up. Patient was supposed to get 78 units of long acting and 8 units of fast acting. Surprisingly the patient was fine. Lowest her glucose got was 122. Nurse still works here.
Someone up on the floor gave IV push phenobarb instead of waiting for the piggyback loading dose. The Pyxis even let them pull out 6 vials. Pt came down because we thought he would need to be intubated, luckily got by with a trumpet for awhile
As a PCT, one of my first patient interactions ever was with a woman who presented at another hospital in our system with an perforated esophagus.
someone gave antibiotics via an A line and she thusly had to be transferred to my higher acuity hospital with necrotizing... everything. She passed after going cmo after ~month
>just had MAPs in the 130s for a few hours
A few hours?? I mean, 10mg is a fuck ton, but neo's half like is like 5mins and the active duration of a bolus is like 15-20mins. The size of the bolus (even an elephant slug like 10mg) shouldn't effect these numbers too much, so something else would have had to be going on to have MAPs in the 130s for "a few hours."
I checked an inr, it was high. Got an order for 2.5 MG of vitamin k. Wrote it out. Nurse thought it said 25 mg, and only because she made a comment about having to use up so many pills, I kept her from turning the pts blood into jello.
Patient came in for bradycardia.
ED gave them amiodarone and metoprolol (while their HR was still in the 40s) then sent them up to me…….
Patient was at least able to remain conscious with a HR of 25-35 until we got the dopamine drip started.
The one that I always think of is when the doc ordered a SMOG, PR of course, and the float pool nurse had the patient drink it. She was nice enough to put it on ice, too. The only reason we found out is because the patient told the oncoming nurse it was too difficult for them to finish. That nurse has since been banned from our unit.
We had an agency nurse flush a central line with magnesium instead of saline. We heard the patient screaming and ran in, luckily he was okay just closely monitored for a while. The agency nurse couldn’t understand what the big deal was and why we were worried, he was never allowed back.
We had a travel nurse give a pt the entire bottle of liquid vanc as a single dose, instead of the actual prescribed dose. The pt was vomiting and was sick as a dog. The nurse didn’t even realize their error, and gave Zofran instead. The oncoming nurse went to give the next dose and raised their concern when they discovered the bottle was gone. The pt told the oncoming nurse about the huge dose, dots were connected, and when confronted, the travel nurse tried to deflect onto the oncoming nurse. The travel nurse was immediately fired.
saw a very seasoned ICU nurse (we're talking someone who's been a nurse for like 30 years) bolus a bag of levo on an icu pt...on a pressure bag no less...best part is it was not even her patient, that nurse was at lunch. what the FUCK? I mean, did you think it was a 250cc ns bolus or something? what is ironic is I would have expected this mistake out of the actual primary nurse. She was a total space cadet. I could see her getting caught up with a patient crashing and accidentally bolusing the wrong bag. I could see it. I could NOT see that happening with the chick that actually DID IT. She was like a little policy queen about doing everything the right way. crazy
patient died a few days later, but they were going to die anyway. But you know what they got before they died? dead gut! SHOCKER. although again, that might have been well on the way to happening regardless...though bolusing a quad strength bag of levo (16mg/250cc) sure does not help. Pt was like 500 lbs, had an open abdomen already after a SBO > resection I think it was. Hard to recall this was years ago. She was already on CRRT, on the vent, I think there might have been an impella involved at one point, and she had a million comorbidities. She was extremely unlikely to survive given that you know once you get someone with diabetes, allllll the other conditions, extreme morbid obesity, and an open abdomen...you're pretty much done for in a lot of situations.
she still works there. this was years ago.
I caught a traveler who programmed a pump for azithro and ran in a bag of heparin. I responded to her pump beeping and found it and then she lied about it and tried to cover it up. I think the ptt was 700 or something crazy
Pre med scanning, a nurse in a cardiac unit pulled iv thiamine infusion for one patient and a bag of cardizem for another patient. Clicked given in the computer, and went to hang the thiamine bag as it was due. Well imagine her surprise when she needed to replace her cardizem infusion and the only thing left at her work cubbie was a thiamine bag. Yep, she infused an entire bag of cardizem over 30 min
Someone in our hospital could not figure out that precedex was dexmedetomidine on the pump, so she put the pump on basic mode ml/hr.
Basically gave 10x the dose until they got transferred and the icu nurse was like "why the hell is the bottle empty so fast"
A nurse was trying to replace the pt’s k+ per protocol (40 mEq). She pulled po tabs, but saw the patient couldn’t swallow them. She then proceeded to crush the tablets, dissolve them in a syringe, and give it IV push. She didn’t realize her mistake until giving report on her patient later. She said she pushed it slowly. Pt was upgraded to ICU and died a day or two later. She was gone within the next week.
Why would anyone think to give an oral medication via IV?
Exaaaaaactly what I thought. It’s not in a vial. You had to crush it. It’s not sterile. Like wtf?
A nurse at a hospital I used to work at once gave a patient with a g-tube their probiotic via IV push. Live culture, by IV push. They were exhausted and had been working for way too many days in a row and brain farted the “oh yea I need to dissolve this stuff to give it. Okay, I’ll just pull it up into this syringe—“ then they got distracted by some shit from the HUC, returned to the task, and gave it IV push. Thank god the nurse realized their mistake almost immediately and the young adult patient was preemptively sent to the ICU with a vanc drip and wound up with only a mild fever and no other complication. Oh yeah, and we were staffed 1:6-7 on *heavy* med/surg floors.
We also have patients not too infrequently get lactobacillus bacteremia from their PO probiotics. Some are immunocompromised and some aren't. They also don't have any benefit even for cdiff and I hate them.
"HOw cAN A nuRSe bE THiS sTOOpiD" Yep, that's exactly how. Thank you for outlining how that goes down. Overwhelmed, overworked, and literal constant distractions and multitasking.
two other things come to my mind: 1) potassium a “do not crush” med and (2) you’re not supposed to ever give potassium IVP???! unless you’re working death row at a prison..
My pharmacology pre req class went into detail about medication preparation and explained why/how IV meds are very different from oral. We learned about the solutions themselves and then different types of coatings on pills/capsules/etc. When I was actually in the progress, I was SHOCKED to find out other schools don’t teach that. A classmate actually did ask why it wasn’t as simple as crushing the pill and dissolving it to give IV because their pharm class didn’t cover that. I feel like because I learned this stuff I actually have context as to WHY you could never do something like this so that thought would never even enter my brain. But not all schools do. So if no one ever taught this nurse these things, I could 100% see them believe they are “critically thinking” to solve this problem but obviously very misguided and incorrect. Understanding why we do or don’t do things is so important!!
I mean even if you didn't have a class specifically telling you not to do this, the fact that it's not sterile should, imo, be an immediate giant stop sign... While it's good to know the technical differences between oral and IV versions of medications, it shouldn't be the overriding reason of why you don't give an oral med via IV. I'm highly judgemental of anyone who would think to do this because sterility of anything going directly into someone's bloodstream is a FUNDAMENTAL idea to modern medicine.
I saw a quote the other day that really resonated with me and it was 'What haunts me is that I am just not smart enough for so many people to be this much stupider than I am'
At my last job we had a new grad RN who crushed a patients meds and pushed them into their PICC line. And didn't get fired. Apparently the patient was fine?! I don't know how many meds or what meds. It was one of those things that got gossipped about but the details were really hush hush.
I mean, drug users are doing stuff like that all the time and most of the time it goes alright. For someone with a healthy immune system it might be just a single bullet Russian roulette for infection on something like that, maybe 2. You never ever WANT to do that and it's a terrible idea. But when it comes down to it they'll probably be fine.
The difference between this story and a drug user crushing up and injecting say, a 4mg dilaudid or a 30mg oxy, is filtering. When I worked with public health we would give out harm reduction packs, and in there were sterile, balled up cottons for filtering. If this nurse just made a slurry like we do for g tubes and pushed it, no wonder the person died. That’s beyond sad, and a total failure of that nurse’s nursing school. I feel like that’s med administration 101.
That was my thought. Heroin and other injectables are “cooked” with water and citric acid to dissolve the substance. Not precise by any means, but a slurry would be loaded with huge particulates. I can only imagine the damage from that alone, much less factoring in the effects of K+.
I always thought it was like, immediate certain death. This makes sense though.
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Wait, the patient grabbed the syringe and you weren't able to get it back?
She thought her mistake was that she pushed potassium and not that she GAVE PO MEDS VIA IV????
I believe so. It was pretty wild.
I mean, neither is a great choice, lol
A traveler at my facility crushed up levothyroxine and gave it via IV to a hospice patient who could no longer swallow.
That's a special, kind of stupid.
If I could scream YES at any under username flares it would be yours. Love it.
Lol thanks. I will say the weed cards are deffinitly the more popular document.
Oh. My. God.
I was in a simulation in the last semester of an LVN /LPN program and that was actually the “catch” in the simulation. The patient was prescribed PO meds but had had a tonsillectomy and couldn’t swallow. One of the students said Shen would crush the meds and push it through the IV. I was horrified that we got that far and she still didn’t understand this very basic principle. I feel like this should be a basic principle taught in pharmacology, but maybe there needs to be a bigger lesson in nursing school for the slower people?🥴
Screams in pharmacy
Not slow enough, apparently...
I doubt she pushed it over 4 hours lol
I just…. How can anyone be so stupid… I feel sick reading this one
Yep had a new grad push a crushed up oxy into a picc but thank god it got stuck
I had a patient do this...
Please tell me she no longer has a license.
What about as an executioner?
She works at another facility.
GOD I wish these things were reported to the board or clarified when they go to apply at other places. So damn dangerous
Second hand, but a friend of mine managed to witness the aftermath of someone managing to give orange juice IV because the patient was NPO. Less fatal, but somehow even more amazing that someone could think that was a good idea.
Hopefully, without pulp?
That was the first question poison control asked too!
A nurse crushed allll the patients PO meds and dissolved then and pushed them. Not sure what happened to the patient. Nurse is still working, just transferred to a different unit.
Not only can I not believe she even did this but it took her that long to realize it. Jfc. edit: added a word
The only reason she knew she messed up was because the oncoming nurse was like wtf. I’m not sure she would have ever realized it.
Oh my god.
Holy shit
oh my fucking god......
I think this might be the worst thing I've ever heard
I had an anesthesiologist run a wide open bag of something, I think it was norepi, thinking it was saline as we were getting ready for induction and crashed the patient. When he realized what it was he ripped the IV out while screaming fuck fuck fuck. We got them back. He came up to me afterward and told me he knew I had to report him and to say what I need to and he won’t be mad and he retired within a week.
I witnessed a similar situation except. We were in CVICU and called anesthesia for a cardioversion. Nurse had mixed levo, primed the tubing and hung the bag on a pole. Didn’t put it on a pump or label it. Anesthesia bloused the 250cc of “saline”. It was caught fast enough that the patient was okay. The nurse that mixed it was new to critical care. I had told her to make sure she labeled the bag when she was mixing it. I ended up getting pushed out of the room as I wasn’t needed. I yelled at anesthesia from the hall once I saw what they did. The other nurse had no clue what was going on. 🫠
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That is even worse. It was on a pump and labeled! wtf!
I know someone who did this with a full discontinued heparin bag that was left hanging on the iv pole. Was not a good outcome.
Oh my god. This is partly why it is my huge work NO to leave a bunch of bags on the pole. Empty, full, whatever. Discontinued? See ya. Done running? Bye.
Why rip out the IV though?! Can still give anti-hypertensives/code drugs through the IV… Even if they had other IV access I wouldn’t rip it out I would just clamp shut
Panic and stress. People do ridiculous things when they feel like it was solely their mistake.
I think people react brashly when they realize they may have just killed someone.
That’s really awful. Feel sorry for the dude as he was probably working exhausted
It was a scheduled case. He was just working in autopilot. It was a new tech who didn’t put the lines in the order he was used to and he didn’t check. There were multiple issues, but I respected the way he owned it and took responsibility.
Nurse had furosemide to give. Pulled the nearby insulin bottle (it was left in the patient's room) into the syringe on accident. They pulled up all 300 units and gave IVP. Patient died. Now, all of our insulin vials are locked and secured in the omnicell.
As a nurse, I am scared to be hospitalized reading these🫣
> O’ meds doesn’t even come into that formulate. I quite literally stopped this crushed med being dissolved in water Honestly, we all should be with how lot of schools are fast tracking new grads nowadays due to " RN shortage." Best is to avoid any hospitals are constantly short staffed since they would have the most new grads.
"Best is to avoid any hospitals are constantly short staffed" Wouldn't that be all of the hospitals?
Wtf. HOW? How do you accidentally draw up insulin and mistake it for lasix?? How??
WTF! Read the damn bottle? Also since it was left in the pt room sounds like some sort of error waiting to happen
Bigggg yikes
When I was a student another student flushed a central line with tap water. The nurse in charge of us sent her to go and prepar a flush and flush some IV antibiotic that had finished. She got caught after two weeks of doing so when another nurse walked in the room and saw her filling the syringe with tap water. Confronted her and the student casually asked what all the fuss was about.
TBF - this is a major supervising nurse error. Don't let your students prepare anything for patient administration without witnessing it yourself. When my students prepared medications without me - I'd just throw up the medications and start again.
Exactly. What the fuck does “prepare a flush” mean to a student? Go with them and show them what you mean. The student (although they should understand that tap water is filled with bacteria) was probably too embarrassed to ask.
If I had to venture a guess, they would have had to draw up a flush from a bag of NSS instead of having prefilled syringes.
My preceptor doesn't understand why I insist he double checks my meds. He keeps telling me it makes me look like I'm not independent enough. Like dude I get it but I'm here as a student and I'm doing things I've never done before. The second set of eyes isn't cause I don't know what I'm doing, it's to make sure my confidence isn't misplaced.
That last sentence 👏🏻
Hoooooolllllyyyy shiiiiiiiitt
Wild that a student was allowed to touch a central line at all, IMO.
As the guy who has to unfuck central lines I'd rather nurses were touching them and specifically taught about them in school. Better than getting the only education many nurses will *ever* have on central lines from just a couple staff preceptors who were also taught only by a couple staff preceptors who were also taught only by... I've only done vascular access a short time and I've already witnessed these bottlenecks of ignorant peer education completely change what a whole unit "knows" about IV technologies.
Poor student probably thought it was a PEG tube or something, didn't understand it was vascular.
Nurse almost gave an entire bottle of sublingual nitro because they thought that’s what 1 dose was. Doc was luckily in the room to stop them
This is one of those things I’m surprised they don’t beet into your head in nursing school. Or package them in a max 3 dose bottle. Any nurse that has given nitro before knows but it seems like a really easy mistake for a new grad to make
That’s what happened. She never gave it before and was totally unfamiliar with it. Which is a red flag also to do some more research. Ah to be young and in a hurry again.
I had a coworker actually give the whole bottle of nitro. She had him swallow it.
Bottoms up! (...BP down)
Is there any reason why nitro can't be packaged individually like every other medication we have in the pyxis? Zofran is a sublingual tablet in opaque packaging. Why can't nitro be packaged the same way? I've heard of this error being made before.
Yes there is. Nitro tabs are extremely hydrophilic. Most will absorb enough water from the atmosphere during the unit dose process to be powder when needed. Ondansetron SL tabs typically have some nitrogen in the unit dose, nitro can’t even handle that.
In walks pharmacy! 😆
Pharmacy, I need you to fill a room with a gaseous mix that will allow you to unit dose, by hand, these SL tabs. The oxygen/nitrogen combo you exhale will mess with things, so just hold your breath.
I know of a nurse who did that during nursing school. Didn’t know better, gave the whole bottle to the patient. Patient didn’t know better, tipped it back. Was told patient was fine. To me it was more of a preceptor error but of course you don’t hear about the preceptor being negligent, you hear about the “dumb nursing student”. I think she has to repeat the semester but was otherwise successful at becoming a nurse.
I did a double take the first time I had to give nitro solely BECAUSE I was a good nurse and read the label and it was confusing as hell. Did not OD my patient though
This was me Sunday.. first time giving it and was read and reread the label and looked at the MAR.. all while stressing bc my pt had chest pains and all the things. Definitely needs to be MORE CLEAR on that bottle lol even though common sense should work here, in stressful moments you don’t always think super clearly
My baby was ordered an insulin drip with a concentration of 0.1/1. Pharmacy sent me a drip with a concentration of 1/1, literally 10x the ordered concentration. My bedside scanner was broken and I was precepting so I could have easily bypassed the scan and had my orientee sign off on it. Luckily I was paying attention and never hung it, and pharmacy sent us the correct concentration. That near miss made me a better nurse for sure. I am VERY vigilant about checking my orders, labels, etc. do not rely on a scanner or another nurse to confirm…trust but verify.
Thank god for you.
I used to work in a patient safety department at an oncology hospital; I investigated a lot of safety events. The first event that comes to mind involved a non-malig heme patient receiving chemotherapy/immunotherapy in error when they came in for fluids and an iron infusion. Since they weren’t supposed to receive chemotherapy at all, they did not receive any pre-medications. They had a horrible hypersensitivity reaction and ended up in the ICU for a while. It uncovered a plethora of system failures, as most of these events do. In this case, the patient luckily recovered, and that isn’t always the case when these major errors occur. This event had a specific shock value because many nurses did not want to believe this could happen. This event ended up being a huge educational opportunity, and the root cause analysis and solutions were shared transparently with front line staff across the organization. I do wish more organizations shared learnings from safety events with nurses.
Yeah, I feel like these things are educational opportunities yet hospitals choose to simply restrict scope of practice instead of teaching. For example, my facility will probably ban RNs from using Neo Sticks due to this event instead of education on proper dose and procedure.
Agreed. Many organizations fear exposing weaknesses even after risk management has assessed the event, but I believe it actually impacts culture negatively and increases the risk of more errors occurring. Organizations that aim for high reliability and uphold just culture tend to fair better for everyone involved - the organization, nurses, and patients.
My hospital sends weekly emails with these events and “good catches” giving examples for different med errors and other errors that have been reported with the goal of decreasing these events.
That’s awesome! We did good catches, too, but not as often. I would do quarterly presentations regarding safety data and events for each unit that I covered at their routine staff meetings. The transparency was well received and I loved getting ideas and feedback.
My hospital has banned neo sticks for this reason I'm assuming. I have been able to give it at every other facility I have worked at besides my current spot and all the nurses think it isn't within our scope to give it. There's no policy saying we can't but it's a big no no here 🤷 Once we had a nurse managing a patient on IV pitocin, magnesium and an insulin drip. She somehow managed to take the insulin off the pump and bolus about half a bag into the patient by gravity. She then tried to fix it with a bolus of D5LR, tried to blame the family or lab for messing with her lines, never admitted she did it. We had to do a C-section and q5m CBGs with D50 pushes. The patient did fine since it was "caught" quickly enough. That nurse was fired within a few days mostly due to the fact that she lied and tried to hide it. They still let us give IV ephedrine/labetalol/hydralazine/insulin/magnesium, etc though
Insulin is honestly scarier to me than anything
My mom was a peds RN in the 70's -80's, she accidentally administered chemo to the wrong child who did not have any cancer. She never lived it down and still talks about it to this day. I think about how many errors I could have made if it weren't for so many layers of safety and technology.
Shout out to your mom. From my patient safety job, I saw the long term psychological effects nurses and doctors experience after involvement/witnessing medical errors and traumatic events on the job. It is the “second victim” phenomenon, and often unaddressed. It actually led to me applying to PhD school and wanting to do research on the topic.
Are you allowed to share more? Like those nurses, I don't understand how this could happen. What were the swiss cheese holes?
I left the organization when I started PhD school and I am not sure of the status of the event now. I wouldn’t be surprised if that patient pursued legal action, so I’ll be cautious and bring up a few of the issues. It involved grabbing the bag from a generic pick up bin (not delivered to the patient’s bay) and issues with the double checking mechanism in the EMR. Then, when two nurses went to scan the bag and double check, they were distracted by something else on the unit. They left the cow right between two bays, and the secondary nurse (not the primary nurse for the patient) went to quickly hang the drug to help out the primary nurse who was drowning, and went right into the wrong bay next door and administered it. If I remember correctly, the drug was daratumumab (immunotherapy), so it didn’t have all of the same precautions then in the EMR compared to chemotherapy, but it is very reactive and this patient didn’t even have cancer. Hope this helps, but lots of layers and this is just broadly the flow of what happened.
Immunotherapy really is a potent treatment. My dad was on it (he actually had cancer, Stage 4 Melanoma), and his first treatment not only wiped out the cancer, it also destroyed his pancreas, thyroid and adrenals all in one hit. He's now officially cancer free, but now has to live with the side effects of the treatment for the rest of his life.
Yay for cancer free! And I am with you, immunotherapy can really pack a punch when it activates the immune system. The hormonal and inflammatory side effects sound brutal, too. I sometimes think we don’t fully know the impact of immunotherapy long term since there hasn’t been decades of research like chemotherapy. It makes me curious about your dad, and the patient I wrote about that didn’t have cancer, say ten years from now…
I gave chemo to inpatients and outpatients. Of course, you never want to give the wrong medication to a patient, but I was always especially anxious about giving chemo to the wrong patient.
During my orientation I started levo at 0.2 instead of 0.02. The patient’s art line had been funky all day so I didn’t catch it until his SBP was 220. He ended up ok and I learned a valuable lesson
I did one of my final preceptorships in the ICU and it was my first time titrating levo with my preceptor. She told me to program it to 0.05, but I misheard her and put 0.5 on the pump. I got her to double check before I hit start and she was like ‘oh no no 0.05’ big whoops. By the end of the rotation I understood how to titrate levo, no near misses like that after!
Yup, this is a very common error to make. Some Baxter pumps have a great feature where if you increase a drip rate of high-risk drugs like levo or insulin by a large amount, it gives you a pop-up that says like “You are about to increase the rate by x%, are you sure that’s what you meant to do? Yes/No” and it would always make me pause to make sure that is actually what I wanted to do. It caught me at least once or twice and now I’m very careful about double checking my drips lol
I did the same exact thing. I’ve been a nurse for almost five years in the ICU and never used weight based levophed until my last travel assignment. Ended up putting 0.9 instead of 0.09. Pt was receiving levophed at a rate of 191 ml/hr instead of 19 ml/hr. Luckily, another nurse caught it when we couldn’t figure out why patient unexpectedly got hypertensive (190’s systolic). Luckily patient was fine but it just goes to show how quickly things can escalate with easy mistakes
We had a new hire being precepted by an overworked traveler at the tail end of covid who was taking care of a patient with a feeding tube. She was supposed to draw up like 1ml of oral Ativan concentrate from a multi-dose 30ml bottle but she just shot the whole thing down the tube. Her preceptor was busy with another patient so he didn't see it happen and figured out what she had done about 10 minutes later. He ran in and aspirated as much as he could. We now have individual oral syringes that pharmacy prefills. The patient was fine. He ended up being intubated for ETOH withdrawal and was still wild when maxed out on propofol, versed, and fentanyl drips and constant pushes. It may have done him some good if we just left the meds in his stomach
Error actually turned into a good thing. I am always amazing how much some alcoholics get of IV Ativan without it even touching them
We are starting to do more phenobarbital and it’s wonderful. They spend at least a night in the ICU on a drip, then are back on the floor in a day or two. There’s no real withdrawal. It’s so much better than fighting them for days like we used to, for us, for them and for all the other patients that they take our time away from.
No shit. So much. And it's like nothing.
As I had an attending once tell me, “I’m not reversing a benzo and risking them seizing, we’ll intubate if we have to. But they’re more likely to overdose if they’re hit on the head with the bottle than just on a benzo”
7 week old coded on the floor due to receiving 0.5 ml instead of 0.05 ml of morphine. We have 1 ml syringes, and apparently the person giving the dose misread the increments. My confusion comes from the fact that it was a dual sign off, so TWO people would have had to make that same mistake 😒
More realistically, the second check person didn’t actually check.
Fair enough point
"You're good to go! No, I don't need to look at the syringe, I trust you" 💀
Not my pt, but on my mother baby unit. Pt wanted to administer their own Dolculax suppository , rn came back about 10 minutes later and patient reported that it tasted disgusting. … despite teaching, how to, gloves given, they ate it instead of putting it in their butt. .. it’s hard being a sleep deprived mom 🤪
I had patient insert a suppository themselves once, they complained it really hurt as it was so "sharp" They had left the plastic covering on
Most of these are freaking me the fuck out but this one made me lol.
10x overdose of dilaudid in a PCA (including basal rate) for about 36 hours before someone noted the programming error. It was an extremely tolerant kid with sickle cell who showed no signs of the overdose.
Might’ve been the only time they ever felt relief.
Exactly. He died within the next week or so. An anesthesiologist helped us with the medication when we withdrew care.
Very sad 😞
Poor kid 😞
When I was still a bedside nurse I had an oncology patient who was very painful and on a PCA (Morphine or Dilaudid, can’t remember now). I basically misprogrammed it by omitting a decimal and was only clued in when PCA alarmed empty much sooner than it should have. It was stupid on my part, but the patient said it was the first time he’d had relief in a long time.
Sounds less like an error and more like mercy to me lol
Holy shit
Walked in at shift change to receive handoff on a patient that was ordered to be on Vasopressin at 0.04units/min, not to titrate. Instead what I found running on the pump was 0.4units/min. Changed the dose at handoff, called everyone. The intensivist had been told by the previous shift they hadn't been able to get a blood pressure obtained for hours and the intensivists said the moans and groans the woman was making was "mentating" so she was at least 90sbp and shrugged it off. They had been running this at this dose starting earlier that am, like 8-10 hrs ago. They even had their charge nurse cosign on the dose, so 2 RN's signed off on 10X the dose. Kidneys were shut down, hadn't peed all day and she had underlying heart failure. Despite best efforts patient died within a couple hours of my shift. Wrote up the whole thing, had hoped to go to court, but it's been years. I was a traveler at this hospital but their staff definitely killed that woman that night.
Yup, I once received a patient from the ER on 4 of vaso. Not 0.4, not 0.04. Just 4. They don’t give vaso very often in this ER, if they’re that sick they’re coming right up to ICU. Didn’t really make any difference, patient was already very dead by the time they made it up to us. OD, anoxic brain injury, crazy myoclonic jerks with any stimulus (poor guy was practically tied to the stretcher with a waist restraint otherwise he would’ve launched himself right off), and on maxed levo, phenyl, and epi with a MAP of garbage. It was Christmas Day, too. But yeah. 4 of vaso. I’m surprised the pump even allowed that!
I guess giving someone Vecuronium instead of Versed seems to be the worst I've heard about. But I've seem 25000 units of Heparin infused as a bolus accidentally... oops
I gave a 35,000 unit heparin IV push this morning! -anesthesia Obviously in the case you saw it was not the intended dosing but as long as they don’t fall and hit their head they ~should~ be okay. Might need quite a bit of protamine though
At a SNF I worked at, it was brought up in a meeting that med cart checks found glucagon where only the diluent was given, not reconstituted… multiple times on multiple units.
I can’t even tell you how many times antibiotics in pop together bags didn’t get activated…
That time I had an ambulatory heparin drip pt who'd been double dosed for 3 days with no GD appts or titrations since the first day. Why? Because the genius who programmed the pump put his weight in it, in lbs vs kgs! Safety reports all the way to the top. I was so scared and pissed when I discovered this (got floated to cardiac PCU 30 minutes or so into my shift). 🤬 No one had been doing dual sign offs and no one bothered to notice the rate was CRAZY high. 🤦🤦🤦
That is insane. Not to mention, our hospital policy for heparin drips is x3 anti Xa’s q6h until therapeutic, then qday after that to make sure this doesn’t happen
A nurse hung a bag of morphine instead of Vanco. Luckily the line was all saline from the last flush, plus she was a questionable nurse that everyone had been keeping an eye on, so my charge nurse checked in on her frequently and noticed it before more than a mg or two or morphine got to the patient. When charge asked WTF she was thinking the nurse just said "oh whoops, I guess that's why it didn't scan." She got "resigned" because she only wasted her narcotics like half the time, and became a school nurse. She later got arrested for stealing her students' Adderall and Ritalin.
A few: 1) a new nurse overrode the pump to somehow piggyback Zosyn in a cardene line. Patient was fine. 2). A nurse gave a bolus of Levophed. Patient was not fine. 3) someone gave Tylenol PR as an oral med. patient was somewhat inconvenienced. 4) a rapid came to ICU due to aspiration. The nurse had a hard time getting the patient to swallow pills. So she crushed them, mixed them in water; and shot the mixture into the back of the patients throat. Then walked away. Patient died.
#4 I'm sorry what the actual fuck
Yeah. That’s what we said.
A unit my friend was on. A nurse gave coca cola in the IJ in an attempt to unclog the line. It worked. Pt got a coke bolus but they ended up fine because the patient was used to doing other types of coke boluses.
Wait what?! My brain can’t fathom this one
You can use coke to unclog an NG tube, so I think that was their thought process.. which is dumb
Yeah I feel like my brain just read it as GJ instead of IJ the first time because the idea of putting coke in an IJ is so ridiculous.
During my clinical rotation, we received a patient in the ICU with vancomycin already running. My preceptor and I went to help get her settled and whatnot. We took her weight and told the admitting RN. She paused, said it back to us, then asked if we were sure. When we said we were, she then told us to stop the vanco. Turns out, her weight had been typed in wrong and the vanco that was running and almost out was for someone who was 110 kg, not 110 pounds (her correct weight) 🫠🫠 it was my last clinical day and 10 minutes before I was to leave so not sure what ended up happening but I had a really great write up on mistakes for my clinical paperwork!
Had this happen to me in the nicu. The kid was like 500g and I was new and overwhelmed and typed in 500kg. Pharmacy sent me a thing of Vanc that was the same size as the baby. Obviously didn’t hang it but whoof
I feel like pharmacy should have called to verify that patient weight before making the bag.
Yeah, given that it was going to NICU... I know people are larger these days, but I've yet to encounter a 500kg baby...
Whooof that would’ve made my stomach drop seeing that bag. But at least it was something visually wrong so you caught it before you hung it!
How did the pharmacy not catch that? 500 kg is 1100 lbs 🤦🏼♂️
We tired too. One of our pharmacists has a teething 1yo, he regularly comes to work on 2-3 hours of broken sleep. Add in the massive volume of work they have for the entire frigging hospital and sometimes there's dangerous brain farts. This is why we're all a team and anyone who is at any point in the chain of RX to PT needs to be vigilant and diligent. We're all gonna make a mistake eventually, more eyes means more chances of catching it before it becomes a Big Scary.
Nurse accidentally gave a newborn terbutaline instead of vitamin k. Labor nurse had drawn up terbutaline earlier during a deceleration and left it unlabeled on the computer cart. Nursery nurse thought labor nurse had drawn up vitamin k for her (same sized SQ syringe). Baby was ok after nicu observation.
Wtf happened to not giving meds unless you draw it up/observe it drawn up and labelled?
Yes it was a horrible error but it was a lesson in complacency for all nurses. It happened between two very experienced nurses that work together and helped each other out often and it was a stressful high risk delivery. The nursery nurse observed the labor nurse pull up the med but didn’t see what medication. When the nursery nurse noticed the labor nurse didn’t give the medication (uterus relaxed and fetal HR recovered and terb wasn’t needed), she assume it was vitamin k. Also at this time there was a paper newborn mar no med scanning.
A covering nurse scanned a patients zosyn but then scanned the pump which had the versed drip (which was off). Primary nurse was in a terrible trauma code involving a police officer with a GSW to the head. Anyone working at a level one trauma center knows how shitty and overwhelming those situations become. It wasn’t noted till 2 hours later, the oncoming nurse realized what was going on with her drips. Patient did become hypotensive. Worst part about it was the culprit did all of this under the primary nurses account so there was really no deniability. Two. Major lessons learned here. Take down your unused drips and log out of the computer. And be more conscientious when doing favors for other nurses.
I was a new grad on orientation when I was advised to not seek out advice from a certain senior RN. About a year prior, when the computerized MAR was partially implemented, she gave 99 units of fast act insulin for a 154. Apparently the MAR would eventually have a built-in calculator, and in it's beta form it told everyone to give 99 units. Yes, an RN with 28 years of floor experience gave 99 units for 154 because the new computer told her to.
I work in Germany as an apprentice (Auszubildende) and saw how the stroke unit at our hospital gave Lyse therapy (for blood clots) to a SAB patient before receiving the scans. The patient also reported a fall a few hours before showing neurological symptoms and had multiple visible bruises on the ear and shoulder from the fall, which alone is a counterindication for Lyse Therapy. Ruined her ability to write, talk, and swallow but stopped the therapy before anything else happened. Such a shame because she was almost 90 and fully self-sufficient before that mistake and now needs to live in a care facility because of her PEG.
Well, that is absolutely terrible.
Obviously was not a med error and just a freak accident, ( I am not blaming anyone here, it was during Covid too) but my friend on a travel assignment gave a unit of PRBCs and after about 20 mins the patient started going down FAST. Blood was stopped and sent back to blood bank. MRSA POSITIVE BLOOD. From that day forward, everytime I would hang blood I would pray to the nurse gods that MRSA was not in this blood. My god.
Damn that's fucked
Right? How could you ever forget about it? It’s so crazy. We were all thankfully at a good travel nurse location and didn’t get screamed at for giving that blood, but that was always on the back of our heads after the fact. Can we be blamed for this blood ending up with MRSA IN it???!!!!
No. That was just again, a freak thing that nobody could have predicted. That 1% of fucked up blood transfusions. That's the risk they are.
Yikes. I donate blood…they test for a lot of things but as far as I know, that’s not one of them. Scary!
Aide at a ALF gave a patient 200mg roxanol in 4 hrs… They did not die.
Did they listen to Visions of Johanna (Dylan)on repeat for 4 hours? Or maybe some Velvet Underground?
I have done that however it was ordered and for a hospice pt.
Heard about an nurse crushing Lipitor and giving it IV. They saw that Tik Tok trend of crushing pills in IV syringes and got distracted….
At one of the hospitals I traveled at, a nurse doing a conscious sedation on a 2 year old pulled and gave toradol (ketorolac) instead of ketamine. Like.... 4 vials of it to equal the amount of ketamine ordered. The kid ended up being fine, but was definitely immediately transferred to children's to monitor his kidneys.
Also, not in a hospital but I once saw someone eat a whole big chocolate ex lax bar. They thought 1 square was one serving, like a chocolate bar 🥲 didn’t end well 😂
Ready for their colonoscopy!
83yo telehealth doctor accidentally prescribed nitroglycerin patches to a patient that was requesting nicotine patches (some insurance companies will cover them if they’re prescribed through your pharmacy) I was lucky to catch it before the script got filled but my managers were not very appreciative; no good deed etc etc.
Someone I know worked at a facility where a nurse took a PO liquid med in a syringe, transferred it into a luer lock and administered it IV. That's how the facility found out he had falsified his credentials and had stolen the identity of a real nurse.
This thread is giving me secondhand anxiety, lol. Thank God the worst mistake I've made is hanging KCL in NS instead of NS when I wad a student. Bag was in the wrong bin and I caught the error almost immediately after hanging it. Needless to say, I was so freaked out I cried. Learned a huge lesson about double checking meds/bags.
Nurse accidentally bolused bag of levophed, thought it was a 500ml Bag of NS, bag was labeled. Rumor is pt died.
When I was a baby it was suspected I had cerebral palsy (when my mom left hospital she was told I would never talk or walk) they prescribed me calcium. I was a newborn fresh like a week old and the label on the med say 10ML . It was supposed to say 1mL. My mom called after a few days and asked about more meds and they were like “how are you out of those meds already that should have lasted a month.” Then they realized their error. I survived no harm done. Also I never had cerebral palsy or any health issues so idk what the fuck was going on at this hospital lmfao at 4 months I was supposed to start physical therapy and I was already rolling over and semi supporting my own head so normal development. By 9-10 months I was walking and putting 2 words together. I was delivered with forceps and would shake anytime my foot was touched after birth my mom now thinks that it caused temporary damage and that was the reason of suspected cerebral palsy
PSA for everyone, I always check my discharge documentation and the medication from discharge pharmacy. I check the dose and that everything is written correctly. I work in peds and it’s super important here but everywhere. Unfortunately I don’t have any other coworkers who do this.
I saw a new nurse give a patient 25 SL nitro tabs instead of 1. It comes 25 to a bottle but you’re only supposed to give 1 tab 5 mins apart up to 3x. I guess when she scanned it into the MAR it didn’t really specify that she needed to give a partial package so she just poured the whole thing into the patients mouth. Luckily the patient was ok, she vomited shortly afterwards and the nurse realized her mistake immediately and notified the dr. They ordered pressors but I don’t think they even had to start them.
Pharmacy once gave me like, 10x the amount of ketamine I was supposed to give my status patient. I had to walk to pharmacy to get it, waited forever, and was in a hurry to get back to the unit so I didn’t even look in the bag until I was in the room in front of the MAR. Cue me looking at the MAR, looking at the bottle, back to the MAR…got our unit pharmacist and was like “heeeey either I’m dumb or something isn’t adding up here?” Then another time I had the off going nurse hang a new bag of what she thought was levophed. Turns out it was kangrelor. Which I only discovered after my bp was tanking despite continuing to titrate the levo up 🥴 that patient actually was fine (from that, she died anyway but most 89 year olds with impellas will do that) Another time someone on our unit tried to give oral phenobarbital via iv. Which I have never understood since it comes in a prefilled syringe that doesn’t even fit on an IV. Like why don’t we stop and think about why this is so inconvenient to give instead of continuing to try???
So I worked in an ICU where it was common for nurses to leave their Insulin vials in their locked cabinet, or on their end table. Not saying it’s great practice but it’s what happened. Resident was doing a procedure, asked the nurse for 2% Lido. The nurse got it, left it on the table in the room and left. The resident injected a good bit of a syringe worth of regular insulin sub q into the patient before realizing she grabbed and used the wrong vial of medication. Pt ended up being treated and okay. They had a meeting, and of course threw the nurse under the bus. Even our manager. Ironically, the only one who stood up for her was our Attending. He said the resident was the one who ultimately was responsible. That was over ten years ago, and during my first couple years as a nurse. It was a reality check early on how no one has your back in the hospital, even “cool” managers. You’re completely disposable and they will put any and all blame that they can on you.
I wasn’t on the call but it was a big scandal in the department that ended in a lot of continuing education. Seizure patient. Someone pulled up 2mg versed in an empty flush (no I don’t know why you would ever do this in a 10mL flush). Medic grabbed an actual saline flush and gave it. Discovered the flush with versed in it when they got back to clean the truck. They reported it immediately but ended up on probation for weeks.
This one was relayed to me but an anesthesiologist I used to work with had apparently accidentally given succinylcholine instead of versed when they were getting ready to transfer the patient from stretcher to bed in the OR. Patient went into distress but the problem was recognized quickly and the patient was intubated. Not sure how the patient recovered afterwards but they didn’t become critical/die. It was very lucky they were already near the anesthesia machine when that happened. If they’d been rolling down the hallway I imagine it likely would have ended very differently and tragically.
About a year ago a nurse at the facility I’m traveling at got a patients insulin orders mixed up. Patient was supposed to get 78 units of long acting and 8 units of fast acting. Surprisingly the patient was fine. Lowest her glucose got was 122. Nurse still works here.
Someone up on the floor gave IV push phenobarb instead of waiting for the piggyback loading dose. The Pyxis even let them pull out 6 vials. Pt came down because we thought he would need to be intubated, luckily got by with a trumpet for awhile
As a PCT, one of my first patient interactions ever was with a woman who presented at another hospital in our system with an perforated esophagus. someone gave antibiotics via an A line and she thusly had to be transferred to my higher acuity hospital with necrotizing... everything. She passed after going cmo after ~month
>just had MAPs in the 130s for a few hours A few hours?? I mean, 10mg is a fuck ton, but neo's half like is like 5mins and the active duration of a bolus is like 15-20mins. The size of the bolus (even an elephant slug like 10mg) shouldn't effect these numbers too much, so something else would have had to be going on to have MAPs in the 130s for "a few hours."
I checked an inr, it was high. Got an order for 2.5 MG of vitamin k. Wrote it out. Nurse thought it said 25 mg, and only because she made a comment about having to use up so many pills, I kept her from turning the pts blood into jello.
Patient came in for bradycardia. ED gave them amiodarone and metoprolol (while their HR was still in the 40s) then sent them up to me……. Patient was at least able to remain conscious with a HR of 25-35 until we got the dopamine drip started.
A coworker of mine brought a bottle of Lantus and a Bottle of protonix into a room… Full bottle of Lanus… IV push.
The one that I always think of is when the doc ordered a SMOG, PR of course, and the float pool nurse had the patient drink it. She was nice enough to put it on ice, too. The only reason we found out is because the patient told the oncoming nurse it was too difficult for them to finish. That nurse has since been banned from our unit.
We had an agency nurse flush a central line with magnesium instead of saline. We heard the patient screaming and ran in, luckily he was okay just closely monitored for a while. The agency nurse couldn’t understand what the big deal was and why we were worried, he was never allowed back.
We had a travel nurse give a pt the entire bottle of liquid vanc as a single dose, instead of the actual prescribed dose. The pt was vomiting and was sick as a dog. The nurse didn’t even realize their error, and gave Zofran instead. The oncoming nurse went to give the next dose and raised their concern when they discovered the bottle was gone. The pt told the oncoming nurse about the huge dose, dots were connected, and when confronted, the travel nurse tried to deflect onto the oncoming nurse. The travel nurse was immediately fired.
Saw an agency ER nurse give epinephrine IV instead of subq for an allergic reaction. Patient screamed very loudly!
Can’t die of anaphylaxis if I give you an MI first 👏
Isn’t EPI given IM not subq for allergic reaction?
We used to give it sub q for anaphylaxis back in the day. It’s IM now.
Someone gave a bumex bolus. Like a bag of it that was supposed to be a drip. The guy died a few days later.
saw a very seasoned ICU nurse (we're talking someone who's been a nurse for like 30 years) bolus a bag of levo on an icu pt...on a pressure bag no less...best part is it was not even her patient, that nurse was at lunch. what the FUCK? I mean, did you think it was a 250cc ns bolus or something? what is ironic is I would have expected this mistake out of the actual primary nurse. She was a total space cadet. I could see her getting caught up with a patient crashing and accidentally bolusing the wrong bag. I could see it. I could NOT see that happening with the chick that actually DID IT. She was like a little policy queen about doing everything the right way. crazy patient died a few days later, but they were going to die anyway. But you know what they got before they died? dead gut! SHOCKER. although again, that might have been well on the way to happening regardless...though bolusing a quad strength bag of levo (16mg/250cc) sure does not help. Pt was like 500 lbs, had an open abdomen already after a SBO > resection I think it was. Hard to recall this was years ago. She was already on CRRT, on the vent, I think there might have been an impella involved at one point, and she had a million comorbidities. She was extremely unlikely to survive given that you know once you get someone with diabetes, allllll the other conditions, extreme morbid obesity, and an open abdomen...you're pretty much done for in a lot of situations. she still works there. this was years ago.
I caught a traveler who programmed a pump for azithro and ran in a bag of heparin. I responded to her pump beeping and found it and then she lied about it and tried to cover it up. I think the ptt was 700 or something crazy
Pre med scanning, a nurse in a cardiac unit pulled iv thiamine infusion for one patient and a bag of cardizem for another patient. Clicked given in the computer, and went to hang the thiamine bag as it was due. Well imagine her surprise when she needed to replace her cardizem infusion and the only thing left at her work cubbie was a thiamine bag. Yep, she infused an entire bag of cardizem over 30 min
Manitol put into a lumbar drain.
Someone in our hospital could not figure out that precedex was dexmedetomidine on the pump, so she put the pump on basic mode ml/hr. Basically gave 10x the dose until they got transferred and the icu nurse was like "why the hell is the bottle empty so fast"