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It can happen to you! January 26, 2009

Posted by 5 Wester in General Announcements.
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I came on my shift and my co-worker was having tough day. The shift haven’t even started for the both of us and he was already busy trying to coordinate a rapid intubation for one of his patients. It’s a good thing we had a CRNA at the bedside who just happened to bring a patient in from recovery. Long story short, we did it just in time.

As they were making phone calls to the appropriate MDs, my co-worker makes a startling discovery. The patient was on an Ativan drip at 25ml/hr, with a 1:1 concentration, he was getting 25mg of Ativan per hour since 1600! Ironically, the pulmononologist on consult for vent management ordered Ativan drip to sedate while on the vent. No wonder the patient’s mentation was steadily declining up until we had to intubate.

As it turns out, this patient was supposed to be on Insulin. As his blood sugar rose to the 300s, his “Insulin drip” was being titrated up, but instead of getting Insulin, someone had spiked a bag of Ativan. What a mess. And to make matters worse, the patient had renal problems too.

There is no doubt that this is a major medication error. A scary fact, but it does happen. We just don’t expect it to happen to us much less a co-worker. But what could have caused such as mixup?

As I contemplated on the events of the day as told by the previous shift who had the patient, I made a few observations which could have prevented the situation if the nurse had followed the simple rule of the “5 Patient Rights to Medication Safety”… Right patient, right drug, right dose, right time, and right route. Unfortunately whoever grabbed the bag of Ativan and started the drip did not verify one of the 5 rights. Looking back, here’s what may have happened.

The nurse in charge had Insulin running. Seeing that he was low on Insulin, he grabbed a bag of what he thought was Insulin from the medication room and hang it on the IV pole, then he took a lunch break. The IV pump starts beeping as the bag empties, someone comes over and seeing a fresh bag of medication spikes the bag of “Insulin” which is actually Ativan, restarts the pump and walks away. The nurse in charge comes back from lunch, takes blood sugars and discovers it is high, titrates the “Insulin” up, not realizing that a new bag of Ativan is hanging. A few hours later, patient is non-responsive and needs to be intubated.

Regardless of what happened, I’m sure you’ll agree that this all could have been prevented if someone, the person who grabbed the bag, or the one who spiked the bag, had remembered to use the simple rule of the “5 Patient Rights to Medication Safety”. This is the reason why I personally do not restart or spike a bag of medication or IV fluid when responding to a beeping IV pump unless I verify with the nurse in charge. It is also the reason I verify the IVs that are running by looking at each bag at the start of my shift, just to make sure we are on the right track.

Leason learned: You can never be too careful, and mind your own business. What a sobering thought! 🙂


How to make your boss listen… do it the MIDAS way! January 7, 2009

Posted by 5 Wester in General Announcements.
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Have you ever talked to your director many times about an ongoing issue in your unit and feel like your words are falling on deaf ears? I’m sure you’ve been in that situation many times before… I know I have.

An article posted by ABC news a year ago mentioned that power causes people to take others less seriously, which explains why your boss doesn’t listen. A recent study shows that your boss doesn’t listen because “there are no consequences”. Fortunately I discovered the secret for making my boss listen to me while I was in a “counseling” session with her one day.

I’m not perfect, and it’s not an excuse, however, some wise *ss day shift nurse thought that writing me up for giving blood “without consent” was a good idea. The fact of the matter is, the patient did give and sign a consent to receive blood… he just had major surgery and was bleeding, Hgb 7.5. Well… my “incident” reached the corporate office risk management department who forwarded the writeup to my director, who called me for “counseling”. At the end of the session she told me to “be careful because these write ups go straight to the corporate office and I have to show them that I took action.” I thanked her and left.

One night, I had to take my patient to CT scan STAT, however, I was having some equipment problems. For some reason, the battery packs on these essential ICU equipment would not charge and therefore, the machine died every time you tried to use it. I’ve told my charge nurse, and my director a few times before, I even wrote her a letter about the situation regarding the poor maintenance of these equipment, but to no avail… this problem had been ongoing for months. How do you get your boss to fix ongoing problems in your unit? Simple… you do it the MIDAS way!

You see, where I work, we have an incident reporting system called “MIDAS+“. It’s a nifty little system that enables you to send an incident report straight to corporate’s risk management office. All I did was to write a report about equipment malfunction in the ICU under “patient safety risk”, hit the SEND button, and wait. Because of the sheer volume of reports they have to deal with, it usually takes about 3 months before they get to read what you send them.

A few months later I was approached by my director in the hallway at the nurses station. She tells me to step aside and starts of with “I’m really bothered about what you sent risk management regarding malfunctioning equipment in the unit. Do you know that when you use the MIDAS system it goes straight to corporate?” “Yes I know”, I replied, “that’s why I used the MIDAS system… so that corporate will know that there is a potential patient safety risk in the ICU”. She tells me to stop using the MIDAS system and let her handle situation because it is her responsibility to do so. I politely reminded her that I did tell her about it many times before, however, the problem still exists.

I may have added to her gray hair, but one thing’s for sure… enough is enough. I’m sure she’ll be more attentive next time. For now, I’m just a thorn in her flesh. I figured, if no one stands up for the patient’s sake, who will?

Well, I don’t recommend using an incident reporting system to write up your boss, however, maybe sometimes you might just get the results you’re looking for. A word of caution though… use at your own risk! Regardless, I know I got her attention. Maybe this time, like she said in her own words, she’ll “be careful because these write ups go straight to the corporate office and I have to show them that I took action.” I thanked her and left. 🙂