mistakes happen

nobody is perfect; everyone makes mistakes. but obviously, some mistakes are more serious than others.

a secretary dials a wrong phone number - no big deal. a bus driver takes a wrong turn - oops, some people are a few minutes late. a barista uses whole milk instead of non-fat - oh well, a customer gets a rich treat!

but when an airline pilot falls asleep - hundreds of people are in danger. when a surgeon mistakes her left from her right - a person ends up losing the wrong limb.

unfortunately, nurses are always the last check when administering medications. it's a huge responsibility. a doctor prescribes a drug. a technician enters it into a computer system. a pharmacist mixes the med. there's room for all sorts of error. but in the end, it's the nurse who delivers the medication and is responsible for the famous five rights:

right patient
right medication
right dose
right time
right route

last night, i caught an error. it could have been hugely serious. a dose of immunoglobulin was ordered for a patient: 60 grams of IVIG diluted in 2 liters of normal saline. the doctor prescribed the right medication and the correct dose. the tech entered the information into the computer. the pharmacist mixed the right medication with some normal saline and filled a 2L bag. and finally, a sticker was printed with all of the correct info.

as the nurse, i received the medication, did my checks, and began infusing it into my sweet patient's central line. it's a serious medication, prescribed for a very serious illness. the medication costs several thousand dollars and is known to cause severe reactions. extra monitoring is required. the medication is started VERY slow and increased cautiously.

after 1 hour and only 62 of the 2000 mL were infused, i noticed something strange. the infusion pump notified me that 1938mL remained; but when i scanned the bag for verification, i noticed the bag did not contain 2L of fluid. i double checked the pump. had i infused the drug too fast? was there a leak? no, no. so, i called pharmacy. they insisted that there was a triple check; they could not have made a mistake. so i asked another RN to assess the bag. perhaps i was crazy and just missing something; perhaps the error was mine.

but then my phone rang; the pharmacist fessed up - there had been a mistake. instead of diluting the medication in 2L, they diluted the medication in 1L and placed it in a 2L bag. my patient had been receiving twice the concentration of the medication. and although the error was made by pharmacy, technically, the error is my fault. i should have noticed the volume; i should have called pharmacy before starting the medication. should my patient have had a serious reaction, it would have been my fault.

when nurses make mistakes, patients can die.

mistakes happen. thankfully this one ended okay.

my patient is safe...

for the time being.