what's the worst mistake you've heard of?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
nafcillin

nafcillin

Full Member
15+ Year Member
Joined
Aug 13, 2008
Messages
285
Reaction score
57
:cool:
Members don't see this ad.
 
At my last hospital...

...someone put in 110 units of insulin with meal rather than what was written...11 units. Patient wound up in a brief coma.

...someone overdosed a dopamine in an ICU patient. They died...obviously of heart complications when their pressure went through the roof.

Worst thing I ever did was put in a Lovenox prophylaxis dose while the patient was on a heparin drip. Which is pretty much nothing in the grand scheme. But I caught more **** for that than either of the above incidents because I wasn't a member of the preferred clique that was tight with the director.

....


Also, when I was an intern back in like 2004, I accidentally put adult vitamin K in the neonatal vitamin k pyxis slot in the nursery. Wasn't completely my fault as it went by the pharmacist...but something like 5 kids got overdosed. Thank God none of them were hurt by it. They just cleared it and all was good.
 
worst one i've known so far was a patient died from anaphylaxis allergic reaciton to Penicillin when an MD ordered a Zosyn and the PharmD let it pass by (without calling or double-checking). Just an hour after, pt got intubated, put into ICU and died a day after. He was still young, too...like 46.
 
Members don't see this ad :)
rxforlife2004 said:
worst one i've known so far was a patient died from anaphylaxis allergic reaciton to Penicillin when an MD ordered a Zosyn and the PharmD let it pass by (without calling or double-checking). Just an hour after, pt got intubated, put into ICU and died a day after. He was still young, too...like 46.
Click to expand...

Zosyn has a gigantic ass side chain on the end of the molecule. Cross sensitivity is actually rather unlikely unless they are sensitive to the actual beta-lactam part of the molecule...which I don't believe is common.
 
DYSF777 said:
This guy I knew took a job at CVS.
Click to expand...

Lol.

During my first retail job several years ago, a pharmacist filled (counted and verified) and amantadine script with amiodarone.

Also, a compounding tech put methadone in a peds dental cocktail instead of demerol and a child died. :(

Thankfully I was not a part of either error, but they are good reminders that we cannot get to comfortable with our day to day duties.
 
Stuff like this scares me, but I need to hear it at the same time to keep me on my toes. Today was the second day of my first IPPE at a health clinic, and just doing the counting for the prescriptions makes me nervous. Don't want to grab the wrong dosage from the shelf, or worse, the wrong meds. I mean, there are a lot of safeguards in place, but I still get nervous just handing the order off to the pharmacist, wondering if I really counted right/took the right bottle.

Overall, I like it though. Next week I'll have to ask the pharms on duty what the worst mistakes they've seen are.
 
Saw a script filled for Oxycontin 15mg, 1 t tid - customer I know- 90 year old lady ( who doesn't weigh 100 lbs soaking wet!). I had just seen her the day before, and she looked fine. Asked the PIC if she had been in an accident. He said not that he knew. I know I'm just a tech- but curiosity and all that......

It was supposed to be for OXYBUTYNIN?

Thankfully, I had nothing to do with that error, but it scared the heck out of me anyway.
 
Oxycontin 15? How did they create that dose?
 
spacecowgirl said:
Oxycontin 15? How did they create that dose?
Click to expand...

I don't know. Like I said- I had nothing to do with the typing/filling/verifying of that one. I just noticed her name on the bag, an peeked at it because I had just sold her what I thought was all of her stuff the day before. Up until now- it was the DRUG I was shocked about- the strength hadn't registered really.

I just checked my version of Epocrates though- and it lists 15 mg as an available dose?
 
KCflacpht said:
I don't know. Like I said- I had nothing to do with the typing/filling/verifying of that one. I just noticed her name on the bag, an peeked at it because I had just sold her what I thought was all of her stuff the day before. Up until now- it was the DRUG I was shocked about- the strength hadn't registered really.

I just checked my version of Epocrates though- and it lists 15 mg as an available dose?
Click to expand...

Yes, there is an available dose of Oxycodone Instant Release for 15 mg.
 
half filling an powder amoxicillin bottle and giving to a patient..patient called back and ask why their liquid was really thick..they never took any
 
Members don't see this ad :)
apteryx said:
Stuff like this scares me, but I need to hear it at the same time to keep me on my toes. Today was the second day of my first IPPE at a health clinic, and just doing the counting for the prescriptions makes me nervous. Don't want to grab the wrong dosage from the shelf, or worse, the wrong meds. I mean, there are a lot of safeguards in place, but I still get nervous just handing the order off to the pharmacist, wondering if I really counted right/took the right bottle.

Overall, I like it though. Next week I'll have to ask the pharms on duty what the worst mistakes they've seen are.
Click to expand...

One of my friends from pharmacy school will not work in hospitals because she just doesn't trust that an IV is going to contain what the label says it does, unless she would make it herself and with a few exceptions, that's not going to happen.

We did have to fire a tech because she got this really crappy boyfriend and was always on the phone, arguing with him, while making IVs and it got to the point where several pharmacists refused to check the bags she made for this reason - and I was going to go to TPTB and add my name to the list on the day she was fired. :( She's a very nice person and on my Facebook friends list, and sadly is still with the boyfriend who's currently in jail. How do I know this? It was on the news a few days ago.

As for the biggest boo-boo I've seen that reached the patient, that person got 2 1/2 times the morphine they should have because of a big whopper of an error that got by the technician, the pharmacist, and the nurse. EVERYTHING about it was wrong, even the size of the bag, and the tech and pharmacist were among the best we had, so this can happen to anybody. The patient did recover fully.

The biggest one that didn't was at a mail order place which was still using manual Baker cells (1993) and someone called the customer service line stating that their Pepcid bottle contained these little round pills that were stamped COUMADIN. :scared: This person was told to destroy those tablets, and we drop shipped a replacement.
 
WVUPharm2007 said:
Also, when I was an intern back in like 2004, I accidentally put adult vitamin K in the neonatal vitamin k pyxis slot in the nursery. Wasn't completely my fault as it went by the pharmacist...but something like 5 kids got overdosed. Thank God none of them were hurt by it. They just cleared it and all was good.
Click to expand...

One of the things I was written up for before I was tossed aside at my last job was an allegation that a newborn order was entered twice and the baby got two Hep B vaccines. They refused to provide any proof of this, nor did they address the nurse's role in this, however which makes me think they made it up.

:idea::whistle: :smuggrin: :zip:
 
Heparin flushes for the NICU. Worthless night tech and Pharmacist compounded them at 1000 times the strength they were supposed to be. 6 little kids were bleeding out of every orface including the pores of thier skin. All recovered except one who was essentially brain dead.
 
The worse I've been involved in was a kid mistakenly got reglan liquid (for several refills/months) instead of ditropan liquid for bedwetting. I really don't know how it got filled that way (the script was pretty clean looking). Luckily the parent was more relieved to understand why it wasn't working. Sounds trivial to kids bleeding out and DA overdoses
 
Just remembered another.

One pharmacist told me about an independent that ordered supplies for a dialysis unit, and some of the dialysate jugs got mixed in with the distilled water. Somebody sold dialysate to a parent instead of distilled water, the parents mixed it with baby formula, and the baby died from a potassium overdose.

:eek:
 
rph3664 said:
Just remembered another.

One pharmacist told me about an independent that ordered supplies for a dialysis unit, and some of the dialysate jugs got mixed in with the distilled water. Somebody sold dialysate to a parent instead of distilled water, the parents mixed it with baby formula, and the baby died from a potassium overdose.

:eek:
Click to expand...

Most dialysate has little to no potassium, for obvious reasons. Containers of dialysate look nothing like jugs of distilled water and the price would be much, much different. This story doesn't make sense. :confused:
 
All4MyDaughter said:
Most dialysate has little to no potassium, for obvious reasons. Containers of dialysate look nothing like jugs of distilled water and the price would be much, much different. This story doesn't make sense. :confused:
Click to expand...

This was many years ago, probably the 1970s.

I'm guessing that the technician grabbed a jug and rang it up at the distilled water price.
 
rph3664 said:
This was many years ago, probably the 1970s.

I'm guessing that the technician grabbed a jug and rang it up at the distilled water price.
Click to expand...

Still doesn't change the fact that dialysate doesn't have much potassium (if any) in it. You understand why, right? This just seems unlikely.
 
npage148 said:
Because I'm bored I looked it up, dialysate has about 1-3 mEq/L K+ compared to pedialyte which has 20 mEq/L so...
Click to expand...

Yeah, I bet the baby formula itself has more potassium in it than the dialysate. I think the story is BS. Maybe a pharmacy urban legend of sorts...
 
I didn't know OxyCotton came in 15 mg. learn something every day.
 
Just don't give me that genetic OxyCotton. I need the stuff that says "OC" on it.
 
spacecowgirl said:
Just don't give me that genetic OxyCotton. I need the stuff that says "OC" on it.
Click to expand...

I had a woman come in wearing a Burka and told me she had to have the "old" Oxycontin because the new formula has pork in it. I thought I had heard everything until that.
 
MountainPharmD said:
Heparin flushes for the NICU. Worthless night tech and Pharmacist compounded them at 1000 times the strength they were supposed to be. 6 little kids were bleeding out of every orface including the pores of thier skin. All recovered except one who was essentially brain dead.
Click to expand...

This wasn't in the San Antonio area ca. 1980, was it? Look up Genene Jones, a pediatric nurse who is believed to have killed some children by doing this on purpose.

"The Death Shift" is by far the better of the two books about this case.
 
rph3664 said:
This wasn't in the San Antonio area ca. 1980, was it? Look up Genene Jones, a pediatric nurse who is believed to have killed some children by doing this on purpose.

"The Death Shift" is by far the better of the two books about this case.
Click to expand...
Genene Jones had to be histrionic. That's what I gathered from reading the story about her on trutv.com.

I get bad intuitive suspicions and feelings about nurses. Nurses scare me!

Here's a link about female nurses who kill (including Genene Jones):
http://www.trutv.com/library/crime/notorious_murders/angels/female_nurses/index.html
 
Last edited:
Fun New Years Day thread :thumbup:

KCflacpht said:
It was supposed to be for OXYBUTYNIN?
Click to expand...

Reminds me of my favourite "stupid criminals" story of the past year, where that guy broke into a pharmacy and stole a large bottle of oxybutynin 5 mg.

Worst error in my city: a pharmacist reconstituted a pediatric amoxicillin script with the bottle of methadone 5mg/mL solution instead of distilled water. The child received a couple of doses and did survive after being rushed to the Hospital for Sick Children. The pharmacist was fired, though perhaps unfairly, because it was a process problem, where they were storing methadone solution and distilled water in similar containers.

In my workplace, a nurse gave a dose of methadone 180mg to a guy with a similar last name on 30mg. She tried to cover up the error, and it was discovered only several hours later (recall how methadone takes a while to reach its Cmax), when the guy's cellmate, a heroin addict of long standing, recognized the symptoms and started calling to the guards for help, saying, "This guy's ODed, and he's gonna die." He saved the man's life, who was rushed to hospital and put on a naloxone drip for a couple of days.

The nurse told management that I was to blame for the error (long story). I was not impressed, and worked with management to facilitate this nurse's retirement.
 
Old Timer said:
I had a woman come in wearing a Burka and told me she had to have the "old" Oxycontin because the new formula has pork in it. I thought I had heard everything until that.
Click to expand...
:D

And me going around thinking it's the pharmacological properties of oxycodone that make it such a popular drug of abuse, when in reality, like everything else that's awesome, it contains bacon.
 
Last edited:
Pharmavixen said:
Fun New Years Day thread :thumbup:



Reminds me of my favourite "stupid criminals" story of the past year, where that guy broke into a pharmacy and stole a large bottle of oxybutynin 5 mg.

Worst error in my city: a pharmacist reconstituted a pediatric amoxicillin script with the bottle of methadone 5mg/mL solution instead of distilled water. The child received a couple of doses and did survive after being rushed to the Hospital for Sick Children. The pharmacist was fired, though perhaps unfairly, because it was a process problem, where they were storing methadone solution and distilled water in similar containers.

In my workplace, a nurse gave a dose of methadone 180mg to a guy with a similar last name on 30mg. She tried to cover up the error, and it was discovered only several hours later (recall how methadone takes a while to reach its Cmax), when the guy's cellmate, a heroin addict of long standing, recognized the symptoms and started calling to the guards for help, saying, "This guy's ODed, and he's gonna die." He saved the man's life, who was rushed to hospital and put on a naloxone drip for a couple of days.

The nurse told management that I was to blame for the error (long story). I was not impressed, and worked with management to facilitate this nurse's retirement.
Click to expand...

That's terrible. I have seen a few med errors from the nursing staff now, but I have never been aware of an attempted cover-up. That's just aweful. We just had a patient on vanco solution po recieve a different patient's IV vanco. The nurse contacted pharmacy as soon as she relized her error (when she went to get the IV for the patient who was supposed to receive it). I also remember a nurse giving the wrong insulin once. But she also came forward right away. That's really bad that she tried to cover it up. :thumbdown:
 
owlegrad said:
That's really bad that she tried to cover it up. :thumbdown:
Click to expand...

The underlying problem, IMO, was major burnout. This woman had a terrible, horrible, awful, absolutely crap attitude, and was continuing to work past retirement age, financial reasons probably, and really shouldn't have been within a mile of any but the healthiest inmates who required nothing more than, say, PO vitamins. I mean, the gauge of needles she used for injections was partly determined by how she felt about an inmate. The bigger an ******* a guy was, the lower the gauge.
 
Old Timer said:
I had a woman come in wearing a Burka and told me she had to have the "old" Oxycontin because the new formula has pork in it. I thought I had heard everything until that.
Click to expand...

Stories crop up periodically during Passover about people who can't take Viagra because it isn't Kosher enough (you Jewish posters, I apologize in advance for not knowing the correct term).

Jay Leno had a skit where a rabbi threw a matzoh ball through a tire swing, as a parody of a Levitra commercial which aired at the time of a man throwing a football through a tire swing. :laugh:
 
Pharmavixen said:
Reminds me of my favourite "stupid criminals" story of the past year, where that guy broke into a pharmacy and stole a large bottle of oxybutynin 5 mg.

Worst error in my city: a pharmacist reconstituted a pediatric amoxicillin script with the bottle of methadone 5mg/mL solution instead of distilled water. The child received a couple of doses and did survive after being rushed to the Hospital for Sick Children. The pharmacist was fired, though perhaps unfairly, because it was a process problem, where they were storing methadone solution and distilled water in similar containers.
Click to expand...

Ever seen the movie "Drugstore Cowboy"? There's a scene where they rob a pharmacy, and all they steal is a box full of laxatives.

As for distilled water vs. methadone, how much methadone did this place use? The methadone solution I've seen was in a 4 ounce bottle.
 
Pharmavixen said:
The underlying problem, IMO, was major burnout. This woman had a terrible, horrible, awful, absolutely crap attitude, and was continuing to work past retirement age, financial reasons probably, and really shouldn't have been within a mile of any but the healthiest inmates who required nothing more than, say, PO vitamins. I mean, the gauge of needles she used for injections was partly determined by how she felt about an inmate. The bigger an ******* a guy was, the lower the gauge.
Click to expand...

I once met a dentist who paid off some of his student loans by working for the Bureau of Prisons for a certain period of time. He liked the guaranteed salary and benefits, etc. but didn't like having to do things like give anesthesia to convicted child molesters.

I sometimes post on a nursing board, and one nurse said (and I sure hope s/he was kidding) that if a known addict came into the ER wanting drugs, he or she was going to squirt some of it out before bringing the syringe into the room. :scared: Sorry, that's just wrong.
 
rph3664 said:
As for distilled water vs. methadone, how much methadone did this place use? The methadone solution I've seen was in a 4 ounce bottle.
Click to expand...

There are about 10,000 people on methadone maintenance in my province, and most of them are in this city where I live. This pharmacy is located in the heart of downtown, and does brisk methadone maintenance business; I have to phone them frequently, as their clients often wind up in the jail.

At the clinic where I worked for 4 years, we went through 4 to 5 litres of methadone 5mg/mL per day.
 
owlegrad said:
That's terrible. I have seen a few med errors from the nursing staff now, but I have never been aware of an attempted cover-up. That's just aweful. We just had a patient on vanco solution po recieve a different patient's IV vanco. The nurse contacted pharmacy as soon as she relized her error (when she went to get the IV for the patient who was supposed to receive it). I also remember a nurse giving the wrong insulin once. But she also came forward right away. That's really bad that she tried to cover it up. :thumbdown:
Click to expand...


At my last job, a vanco Add-Vantage hung on a patient's bedside pole, unactivated and not given, for 16 hours. I got in more trouble for writing "Nobody noticed this for 16 hours?" on the incident report than the nurses did for doing this. And this was on a med/surg floor, not ICU or some other place where a person's gonna have a bunch of IV bags.
 
A pharmacist I worked with, who was either a resident or just a new practitioner, filled an IV hydrocortisone order--100 mg or so--with hydralazine. Patient coded, but survived.

The worst part for me was when he showed me the order and asked "doesn't that look like hydralazine?" I looked and said, diplomatically, "...um....yeah...."

It was obviously hydrocortisone. :scared:
 
And a funny one too.

A dialogue;

*phone rings*

Me: "Inpatient pharmacy"

Nurse: "Hi, there is an order here for a Heroin 5000 units subq Q8hrs since yesterday, and..."

Me: "I'm sorry, an order for what?"

Nurse: "A Hero...oops, it actually says Heparin...*laughter*"

She almost went for it a second time. Beat that!
 
You must log in or register to reply here.
Next unread thread

Similar threads

sunnyandseventytwo
Longest shift you've ever worked?
Replies
30
Views
2K
BidingMyTime
BidingMyTime
pharm B
Mass NAPLEX Score Mistake?
Replies
23
Views
3K
Rockinacoustic
Rockinacoustic
P
Binghamton University's Pharmacy School - Possibility to Be Worst in NY?
Replies
16
Views
3K
samven582
S
E
What's The Market Like For A Compounding Pharmacy?
Replies
1
Views
834
RXDOC1986
R
G
What's the expense ratio on your 401k funds?
Replies
25
Views
1K
confettiflyer
confettiflyer
Top