Discovering an error. Pharmacy Error or Nursing Error

[Sparda29]

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So I found an error today, can't figure out if it was a pharmacy error or a nursing error.

#1 - MD orders NaCl 3%, 80 ml over 2 hours.
#2 - Pharmacy enters the order as NaCl 3% 80 ml 1X dose over 2 hours and dispenses a full 500 ml bag of NaCl 3% with the label and a high alert sticker.
#3 - Nurse calls down saying the bag ripped and requests a new bag. I reprint it and send it up.
#4 - Nurse calls 2 hours later stating the doctor called and is furious about something and asks me to call doctor.
#5 - I call doctor, he wants me to investigate what happened. I go upstairs and find that the nurse instead of administering only 80 ml out of the bag, has administered 240 ml. WTF

Now we gotta cancel surgery, change the IV fluids, DC lasix.

Now I'm just paranoid about if this was a pharmacy error or a nursing error.

http://www.sort.nhs.uk/Media/Guidelines/Hypertonicsaline3NaCIguideline.pdf

This chart leads me to believe that it was a nursing error.

 

[rph3664]

It's a nursing error, BUT for an amount that small, I've always drawn out that amount (or had the tech do it) and put it into an empty bag or glass bottle.

 

[ucrx]

So I found an error today, can't figure out if it was a pharmacy error or a nursing error.

#1 - MD orders NaCl 3%, 80 ml over 2 hours.
#2 - Pharmacy enters the order as NaCl 3% 80 ml 1X dose over 2 hours and dispenses a full 500 ml bag of NaCl 3% with the label and a high alert sticker.
#3 - Nurse calls down saying the bag ripped and requests a new bag. I reprint it and send it up.
#4 - Nurse calls 2 hours later stating the doctor called and is furious about something and asks me to call doctor.
#5 - I call doctor, he wants me to investigate what happened. I go upstairs and find that the nurse instead of administering only 80 ml out of the bag, has administered 240 ml. WTF

Now we gotta cancel surgery, change the IV fluids, DC lasix.

Now I'm just paranoid about if this was a pharmacy error or a nursing error.

http://www.sort.nhs.uk/Media/Guidelines/Hypertonicsaline3NaCIguideline.pdf

This chart leads me to believe that it was a nursing error.

I don't care how the error is classified. What is more important is to figure out how it could be prevented. To me, sending a 500 ml bag when the order is for 80 ml is setting up for an error, and should not be done especially for something considered high risk.

 

[rph3664]

I don't care how the error is classified. What is more important is to figure out how it could be prevented. To me, sending a 500 ml bag when the order is for 80 ml is setting up for an error, and should not be done especially for something considered high risk.

AGREED! And this was why we sent up a smaller amount.

My paternal grandmother was hospitalized several times for critically low sodium levels, my father has been too, and I appear to have the same condition myself. The first time it happened to my dad, they wouldn't hang the 3% NS until they had the labs back, which puzzled my mother until I told her that this was a very dangerous infusion.

After Grandma went to a nursing home and this happened again, Dad said, "I'm going to get a bottle of salt tablets and give them to her nurse, and tell her to make sure my mother takes them!" I replied that this was a good idea, but that Grandma could not have anything like that unless the doctor ordered it, even if it was OTC.

p.s. I'm surprised that patient didn't get phlebitis, unless it was infused through a central line. We never gave it at a rate higher than 50ml/hr, except for one time when the nephrologist DEMANDED 100ml/hr for a sodium in the 100s, and he compromised at 67ml/hr.

 

[Its Z]

Pharmacy error.

Twice.

Since the order was for 80 mL but you guys sent 2 bags of 500 mL of high alert medication.

They will probably fire you.



Ehh...just ****ing with u

 

[cycloketocaine]

Pharmacy error.

Twice.

Since the order was for 80 mL but you guys sent 2 bags of 500 mL of high alert medication.

They will probably fire you.



Ehh...just ****ing with u

 

[ttopping]

Both nursing and pharmacy in my opinion. The nurse for not following the directions, pharmacy for entering the order as 80ml x1 over 2 hours and then sending a 500mL bag. Those directions read as a bolus. An order like that is just asking for trouble.

Maybe it's easier with our computer system, but I would have changed the order around to read as a continuous infusion, 40mL/hr x 2 hours. Much less confusing in my opinion. Thoughts?

 

[nnguyenc]

situations like this aggravate me, you will have to idiot proof everything you do for now on

if the patient all of sudden became hyponatremic, you would be getting a pat on the back for giving a little extra so they don't have to wait for another order

there's a difference when you give a toddler a sharp knife to eat with versus an adult

 

[Sparda29]

Pharmacist who entered it (someone who's been here 10+ years) told me that this is how it was always done at our hospital and it was the nurses job to make sure the correct amount is infused. 😕

 

[Its Z]

Pharmacist who entered it (someone who's been here 10+ years) told me that this is how it was always done at our hospital and it was the nurses job to make sure the correct amount is infused. 😕

Oh hell why didn't you say so...

If that's the case...then carry on..

Why improve a process for a better outcome when you can keep doing what you've been doing.

 

[Praziquantel86]

The goal of a root cause analysis is to identify breakdowns in the system and fix them, not assign blame. By the sounds of it, there were multiple issues involved. Unclear instructions on the label, incorrect dispensing amounts, failure to cross-check the administered dose with the written order, etc.

Don't find someone to blame, find a way to plug the holes in a leaky ship.

 

[Sparda29]

Both nursing and pharmacy in my opinion. The nurse for not following the directions, pharmacy for entering the order as 80ml x1 over 2 hours and then sending a 500mL bag. Those directions read as a bolus. An order like that is just asking for trouble.

Maybe it's easier with our computer system, but I would have changed the order around to read as a continuous infusion, 40mL/hr x 2 hours. Much less confusing in my opinion. Thoughts?

Our pharmacy system is archaic and is being upgraded in January. System makes you enter NaCl3% in the PO drugs screen. Doesn't let you enter rates or anything like that in the PO screen.

 

[smercer]

Oh hell why didn't you say so...

If that's the case...then carry on..

Why improve a process for a better outcome when you can keep doing what you've been doing.

Eh...From the other posts Sparda has made about this hospital, it would seem like they need to revamp a lot of their processes.

Maybe Sparda should suggest they look into having someone review their processes to improve the quality of patient care.

 

[confettiflyer]

Trick question. It's neither pharmacy nor nursing...it's a system error!

Tip your waiters/waitresses.

 

[Sparda29]

Eh...From the other posts Sparda has made about this hospital, it would seem like they need to revamp a lot of their processes.

Maybe Sparda should suggest they look into having someone review their processes to improve the quality of patient care.

The hospital is slowly rebounding. It was going to close 10 years ago before it was bought by a major health system, it's still losing close to $20 million/year, better than where it was 10 years ago.

 

[group_theory]

Oh hell why didn't you say so...

If that's the case...then carry on..

Why improve a process for a better outcome when you can keep doing what you've been doing.

The goal of a root cause analysis is to identify breakdowns in the system and fix them, not assign blame. By the sounds of it, there were multiple issues involved. Unclear instructions on the label, incorrect dispensing amounts, failure to cross-check the administered dose with the written order, etc.

Don't find someone to blame, find a way to plug the holes in a leaky ship.

Trick question. It's neither pharmacy nor nursing...it's a system error!

Tip your waiters/waitresses.

I was about to say ... this sounds like a systems error that should be looked into and corrected. Central Pontine Myelinolysis is bad, and puts all providers and the hospital at huge legal risk (recent verdicts dealing with CPM have resulted in multimillion dollar verdicts)

Fortunately it doesn;t happen every time you rapidly correct hyponatremia, but it is something that you have to be careful, especially in the setting of chronic hyponatremia.

The question is - how can this be prevented in the future. Placing blame or deciding blame (nursing vs pharmacy error) only encourages people to be defensive (and point fingers). Creating a system where anyone (from your techs, to the CNAs to physicians/nurses/pharmacists) can report near-misses without fear of retaliation is the first step. Then you need someone (or a committee) to decide where the breakdown occurred, the type of breakdown, and how it can be prevented in the future. This could be done as part of a quality improvement project (if there are students rotating, residents rotating, or if someone wants to climb the leadership ladder)

What is done is done. But now the hospital (and its various subgroups) need to look at it to figure out how to prevent this from happening again. (and while having CPOE and EMR might fix some problems, there will be other problems that would not be addressed ... and anytime you have humans involve in the process, errors will always be a possibility)

 

[rph3664]

The hospital is slowly rebounding. It was going to close 10 years ago before it was bought by a major health system, it's still losing close to $20 million/year, better than where it was 10 years ago.

Rhetorical, slightly off-topic question: Does your hospital have a burn unit? I'm asking, because here in the Midwest, some hospitals have had to close their burn units because the whole hospital was in danger of bankruptcy from the uninsured people who blew themselves up in meth lab explosions. These units are not located in small hospitals, either. Some medical ethicists are even discussing whether meth lab explosion "victims" should even get any treatment beyond comfort care - it's that bad.

😱

 

[Sparda29]

Rhetorical, slightly off-topic question: Does your hospital have a burn unit? I'm asking, because here in the Midwest, some hospitals have had to close their burn units because the whole hospital was in danger of bankruptcy from the uninsured people who blew themselves up in meth lab explosions. These units are not located in small hospitals, either. Some medical ethicists are even discussing whether meth lab explosion "victims" should even get any treatment beyond comfort care - it's that bad.

😱

No burn unit, but we do have a wound care unit with hyperbaric chambers to accelerate wound recovery.

I was about to say ... this sounds like a systems error that should be looked into and corrected. Central Pontine Myelinolysis is bad, and puts all providers and the hospital at huge legal risk (recent verdicts dealing with CPM have resulted in multimillion dollar verdicts)

Fortunately it doesn;t happen every time you rapidly correct hyponatremia, but it is something that you have to be careful, especially in the setting of chronic hyponatremia.

The question is - how can this be prevented in the future. Placing blame or deciding blame (nursing vs pharmacy error) only encourages people to be defensive (and point fingers). Creating a system where anyone (from your techs, to the CNAs to physicians/nurses/pharmacists) can report near-misses without fear of retaliation is the first step. Then you need someone (or a committee) to decide where the breakdown occurred, the type of breakdown, and how it can be prevented in the future. This could be done as part of a quality improvement project (if there are students rotating, residents rotating, or if someone wants to climb the leadership ladder)

What is done is done. But now the hospital (and its various subgroups) need to look at it to figure out how to prevent this from happening again. (and while having CPOE and EMR might fix some problems, there will be other problems that would not be addressed ... and anytime you have humans involve in the process, errors will always be a possibility)

That's exactly what the attending was afraid of.

 

[Sparda29]

It would be a good education project to look into. The same nurse like 2 hours after that error was found took a telephone order from the doctor wrong. She said the doctor ordered 1L Normal Saline with 20 meq of sodium chloride. I call the doctor and tell him this, he just laughs and says thanks for calling me. It was supposed to be 1L Normal Saline with 20 meq of potassium chloride.

This particular attending used to be a pharmacist so I was like, there's no way he would order that.

 

[amox]

They make 100ml bags right? take out 20ml?

Or just send 100 for nurse to administer 80. Would save lots of $ over time

 

[Sparda29]

They make 100ml bags right? take out 20ml?

Or just send 100 for nurse to administer 80. Would save lots of $ over time

All we have are 500 ml bags.

 

[Rebel78]

Doesn't really matter who's fault it is, only thing that matters is correcting it.

On the pharmacy end, I would correct the label. If the system won't print a rate, write it on there with an ink pen. I would never send a bulk bag of hypertonic saline with 6 times the ordered amount, it takes just a second to pull it out and throw it in an empty bag. I worked at a hospital that only had liter bags of 3%, would anybody be comfortable sending a liter on an 80 ml order? I wouldn't think so.

 

[awval999]

Just thought you'd like to know this:
I'm working-- Thanksgiving-- the only pharmacist in the hospital.
Order for 3% NaCL 30mL/hr over 4 hours. Total volume 120mL.

I thought of this thread.
I had the tech pull 120mL out of the 500mL bag and put into into a viaflex.

Thanks bud.

 

[Rx MPLS]

The goal of a root cause analysis is to identify breakdowns in the system and fix them, not assign blame. By the sounds of it, there were multiple issues involved. Unclear instructions on the label, incorrect dispensing amounts, failure to cross-check the administered dose with the written order, etc.

Don't find someone to blame, find a way to plug the holes in a leaky ship.

👍
Why this isn't the standard response to issues in this world continues to amaze me to this day.