Anyone care to share a "mistake" story?

[CYP3A4]

I am an overnight pharmacist at a 450-bed hospital. It can get VERY busy. I only have one tech and the nursing staff at my hospital is horrible. i spend 90% of my night answering the most ******ed questions. Anyhoo, I have been here a year and I made my first error. I received an antibiotic order from the nursery. The order was for Vanco, Claforan and a TPN. I started working on it immediately. Checking doses, volumes, concentrations etc. Within 2 minutes the nurse calls me "we just scanned you an order that is super stat!!!! we need it right away!! did you get it!?"I was slighly annoyed but understood the urgency. Obviously the call distracted me, i told the nurse we would have everythign ready in 30 minutes.3 minutes later another nurse calls, "i know we already called you but this really needs to get up here sooner than 30 minutes. The doctor is stand right here, blah blah blah...."So now I am officially pissed and I told the nurse that this is the second interruption I have had trying to process this order. I kindly asked her to not call me anymore. I hung up and ironically I said to my tech "see, this is how mistakes happen!"Long story short, the neonatologist wrote for 100mg/kg of vanco, not 10mg/kg. I missed it too, with all the phone calls I probably bypassed the alert on the computer. The baby was fine when all was said and done but the part that gets me is that they didnt hang the drug until 2 hours later because there was no line access. I know this wasn't entirely my fault but I hate when stuff like this slips past me.

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[Bernoull]

I am an overnight pharmacist at a 450-bed hospital. It can get VERY busy. I only have one tech and the nursing staff at my hospital is horrible. i spend 90% of my night answering the most ******ed questions. Anyhoo, I have been here a year and I made my first error. I received an antibiotic order from the nursery. The order was for Vanco, Claforan and a TPN. I started working on it immediately. Checking doses, volumes, concentrations etc. Within 2 minutes the nurse calls me "we just scanned you an order that is super stat!!!! we need it right away!! did you get it!?"I was slighly annoyed but understood the urgency. Obviously the call distracted me, i told the nurse we would have everythign ready in 30 minutes.3 minutes later another nurse calls, "i know we already called you but this really needs to get up here sooner than 30 minutes. The doctor is stand right here, blah blah blah...."So now I am officially pissed and I told the nurse that this is the second interruption I have had trying to process this order. I kindly asked her to not call me anymore. I hung up and ironically I said to my tech "see, this is how mistakes happen!"Long story short, the neonatologist wrote for 100mg/kg of vanco, not 10mg/kg. I missed it too, with all the phone calls I probably bypassed the alert on the computer. The baby was fine when all was said and done but the part that gets me is that they didnt hang the drug until 2 hours later because there was no line access. I know this wasn't entirely my fault but I hate when stuff like this slips past me.

I'm not sure if the doctors at ur hospital use an EMR system, if they do, isn't there kind of "alert" especially given the 10 fold discrepancy?

My background is in Pharma QC and engineering, and sometimes I feel like the medical world is way behind other industries when in comes to "systems QC".

Also, for a "near miss" like this, is there any formal investigation (from either the medical or pharmacy side), root cause analysis and corrective action implementation to prevent recurrence?

 

[CYP3A4]

My hospital won't have CPOE until later this year. So everything is still paper. When I was informed of the error, my director was very explicit that she wasn't blaming me. I am very grateful that I work at an institution that doesn't believe in the "blame and shame" approach to handling errors. For my defense, I simply explained that the excessive phone calls from nursing, in this example and many others, needs to stop. One pharmacist can't process orders and pick up the phone every 2 minutes to be harrassed by poorly trained nurses. I am surprised I haven't made any other errors in the past!Anyhoo, I want people to share their stories. I hate feeling like the only loser lol

 

[awval999]

My hospital won't have CPOE until later this year. So everything is still paper. When I was informed of the error, my director was very explicit that she wasn't blaming me. I am very grateful that I work at an institution that doesn't believe in the "blame and shame" approach to handling errors. For my defense, I simply explained that the excessive phone calls from nursing, in this example and many others, needs to stop. One pharmacist can't process orders and pick up the phone every 2 minutes to be harrassed by poorly trained nurses. I am surprised I haven't made any other errors in the past!Anyhoo, I want people to share their stories. I hate feeling like the only loser lol

You need another pharmacist. I work at a ~500/bed hospital. We have two pharmacists and two technicians at night.

 

[Sparda29]

My worst error resulted from me trusting the system too much. The days I'm scheduled, I'm the only intern/tech pulling and labeling meds. Usually, there are orders to be filled from 2-3PM lying around along with the new admissions, so I end up filling about 150 orders in a 4 hour shift by myself. When I get into a groove of filling the orders, I have a tendency to overlook some things.

This particular error, the order was for a card of Lovastatin 10 mg. I went to the box of Lovastatin 10 mg cards, pulled it, labeled it, and threw it into the basket to be checked. It got checked and sent to the patient, and no one realized the error until 3 weeks later. The patient received Lovastatin 40 mg instead of Lovastatin 10 mg. The tech who makes all the cards and packs them onto the boxes on the shelves placed the 40 mg cards in the 10 mg box.

There was no complaint from the patient about muscle weakness, and LDL was reduced to therapeutic goal.

 

[spacecowgirl]

How can your hospital be so terribly under staffed? My hospital has way more staff and is many times smaller. That is ridiculous and dangerous and I would be far too stressed working someplace like that. Good lord! They shouldn't be able to order tpn at night when you are so short staffed. I feel bad for you and pissed that any administration would think that is acceptable.

 

[PharmDstudent]

They shouldn't be able to order tpn at night when you are so short staffed. I feel bad for you and pissed that any administration would think that is acceptable.

Exactly. They can always run a blank Clinimix until the TPN can be figured out.

That 450-bed hospital better not have Med units, because that would be too much volume for one person. What are they thinking?

In LTAC where I work, 23 patients = full.

 

[njac]

Exactly. They can always run a blank Clinimix until the TPN can be figured out.

That 450-bed hospital better not have Med units, because that would be too much volume for one person. What are they thinking?

In LTAC where I work, 23 patients = full.

Clinimix for a NICU baby?! I think not.

But there should be stock solution generic NICU TPNs available for 1st bags. We have 2 formulas available and always have 2-3 of each bag made up.

 

[CYP3A4]

Thanks for all the responses.....and sympathy! The hospital changed ownership (we are now HCA) and volume/census is picking up. I suspect and hope that if HCA reaches their census goals that extra help will be given to me.

 

[Its Z]

Thanks for all the responses.....and sympathy! The hospital changed ownership (we are now HCA) and volume/census is picking up. I suspect and hope that if HCA reaches their census goals that extra help will be given to me.

Couple of things...claforan, vanco, and tpn are never a stat. Especially for neonates. Especially with tpn at nightshift when you dont have another pharmacist to double check. HCA? good luck with that. they have he most stringent staffing goals in healthcare. I was a DOP and a regional person for HCA some years ago. By far the worst employer ever.

 

[Its Z]

Clinimix for a NICU baby?! I think not.

But there should be stock solution generic NICU TPNs available for 1st bags. We have 2 formulas available and always have 2-3 of each bag made up.

What expiration do you give for those TPNS?

 

[cycloketocaine]

Couple of things...claforan, vanco, and tpn are never a stat. Especially for neonates. Especially with tpn at nightshift when you dont have another pharmacist to double check. HCA? good luck with that. they have he most stringent staffing goals in healthcare. I was a DOP and a regional person for HCA some years ago. By far the worst employer ever.

Ha!! I practice at an HCA facility.

 

[npage148]

Wasn't me but I had to deal with the aftermath of a kid getting liquid reglan instead of ditropan for bed wetting. I think he ended up going through 2 refills before anyone caught it. Mom wasn't that made, more frustrated with how it wasn't working.

 

[PharmDstudent]

Clinimix for a NICU baby?! I think not.

But there should be stock solution generic NICU TPNs available for 1st bags. We have 2 formulas available and always have 2-3 of each bag made up.

It depends on their weight and/or age. At 10 kgs, the dose is 1-2.5 g/kg according to American Academy of Pediatrics.

 

[Glycerin]

But there should be stock solution generic NICU TPNs available for 1st bags. We have 2 formulas available and always have 2-3 of each bag made up.

Same here.

 

[Glycerin]

claforan, vanco, and tpn are never a stat.

True that, and the same applies for most other drugs flagged as stat.

 

[njac]

It depends on their weight and/or age. At 10 kgs, the dose is 1-2.5 g/kg according to American Academy of Pediatrics.

How often is a stat nicu tpn for a 10kg baby? I feel confident in saying never.

The stat nicu tpns are usually for the brand new babies.

 

[PostHaste]

I do all the RCAs for our facility, and just so you know, you're not alone. The interruptions cause a lot of errors. I am surprised at your staffing; we're closer to 200-250 census and there have been multiple errors that were found to be in part due to there only being 1 pharmacist on nocs.

I'm not sure if the doctors at ur hospital use an EMR system, if they do, isn't there kind of "alert" especially given the 10 fold discrepancy?

My background is in Pharma QC and engineering, and sometimes I feel like the medical world is way behind other industries when in comes to "systems QC".

Also, for a "near miss" like this, is there any formal investigation (from either the medical or pharmacy side), root cause analysis and corrective action implementation to prevent recurrence?

x1000 (Though the alerts are questionable at best in their usefulness in many cases...)

 

[Glycerin]

How often is a stat nicu tpn for a 10kg baby? I feel confident in saying never.

The stat nicu tpns are usually for the brand new babies.

+1. A 10 kg NICU baby would be enormous. It's, like, a ten-fold--even sometimes twenty-fold--increase of reality.

 

[StevePerry]

Couple of things...claforan, vanco, and tpn are never a stat. Especially for neonates. Especially with tpn at nightshift when you dont have another pharmacist to double check. HCA? good luck with that. they have he most stringent staffing goals in healthcare. I was a DOP and a regional person for HCA some years ago. By far the worst employer ever.

He speaks the truth...

 

[StevePerry]

I was a DOP and a regional person for HCA some years ago. By far the worst employer ever.

So thats not the gig you just quit to go back to being a DOP?

 

[Its Z]

So thats not the gig you just quit to go back to being a DOP?

No

 

[hsb1104]

Haha.. I'm at a 350 bed (with 2 new wings in the works) HCA facility with one tech and pharamacist at night and I'm fairly certain that isn't going to change... especially with CPOE coming.

 

[PharmDstudent]

How often is a stat nicu tpn for a 10kg baby? I feel confident in saying never.

The stat nicu tpns are usually for the brand new babies.

Yeah... probably very rare. My younger brother was 10lbs 1oz whenever he was born. My perspective is probably off.

But hell, if the child will die within that 30 minutes because of a burn, then running a blank is better than nothing. They were acting like it was an emergency, afterall.

 

[njac]

Yeah... probably very rare. My younger brother was 10lbs 1oz whenever he was born. My perspective is probably off.

But hell, if the child will die within that 30 minutes because of a burn, then running a blank is better than nothing. They were acting like it was an emergency, afterall.

Nah, if it's a burn we're doing fluid resuscitation Parkland-style http://www.mdcalc.com/parkland-formula-for-burns/

I'm far from a child lover and am actually in the category of baby hater, but neonatal TPNs are an emergency - that is why you should have stock solutions available. (will look up our expiration dating next time I work) An adult or an older kid, hang some D10 and call me in the morning Bebes? Notsomuch.

we often joke that the 8lb baby who is there for a day or two post partum could eat all the 800grammers around it.

 

[PharmDstudent]

Nah, if it's a burn we're doing fluid resuscitation Parkland-style http://www.mdcalc.com/parkland-formula-for-burns/

I'm far from a child lover and am actually in the category of baby hater, but neonatal TPNs are an emergency - that is why you should have stock solutions available. (will look up our expiration dating next time I work) An adult or an older kid, hang some D10 and call me in the morning Bebes? Notsomuch.

we often joke that the 8lb baby who is there for a day or two post partum could eat all the 800grammers around it.

Same here. Babies aren't my thang. My 5lb cat died recently, though, so maybe it's messing with my mind. You know, loss of life and all.

Gotcha. I'll fly the next baby to California then so that you can help them.
Thankfully I don't have to work with those fragile peds. It would stress me the heck out.

I was 8lbs whenever I was born. My siblings and I just kept getting bigger and bigger.

 

[StevePerry]

No

Wow... higher than HCA regional... I never realized that you had THAT much experience!

You just doing the DOP gig for a M-F 9-5 white-picket fence thing?