Caught a big med error!

6 I went to work the other day, Cardiac ICU. And most of the nurses at my work do not do a bedside report. I often will go check the room just to see what state my patient is in, what drips they are on, etc. I saw that my pt's BP was 80 systolic, curious I looked at the lines, saw Levophed was hanging, and checked the bag...which read Azithromycin. Realized that there was no vasopressor hanging on this ladies BP. So even though I had not received report yet, I hit the hold button, and ordered a bag of levophed stat, grabbed the RN while she was still giving report and showed it to her.
This is an excellent nurse, often works charge and resource, has been around for 10 years and it happened to her. Same with the day nurse who is assumed to have hung the medication. And I, the nurse with a year experience, caught it.
It was reported and everything is going through proper commands.
Just wanted to share, hopefully it will help someone else from making the mistake. I often check all my bags multiple times during a shift, see how I'm doing on fluids and plan to reorder new bags early so I don't run out. But it can happen to anyone.
GOOD JOB~ that is what it's all about. Trust me, if you spend a considerable amount of time on the job, you will make some kind of mistake, or come near it. And hopefully, you or someone equally vigilant, will catch it before it happens or does harm.

Nice work! Hats off to your observing this! Curious why it isn't mandatory for two RNs to check off a pressor when hanging it? I mean we have to do it when hanging chemo, why not with lethal drugs like leave's em dead (Levophed)?

In my ICU, it is not required to re-check your drips with a second person if you are just hanging a new bag -- it's required at shift change and when you get handoff from the PACU/OR or another ward. But yep, that was a biggie -- luckily it was caught quickly. Along the same lines, a nurse I work with was covering a lunch for another nurse that had a post-op CABG (about 3-4 hours out of the OR.) I noticed that the B/P was beeping low (70/40s) at the central monitors and alerted her to it and told her a pump was going off in the room as well (she wasn't in the room, obviously.) She told me the art line was positional. I go into the room to fix the pump, and the neo was out. Ah hah -- it was a perfectly functional art line after all. Luckily the nurse had re-ordered the neo prior to her leaving for lunch and there was an extra bag at the bedside, so it was easily remedied. But, goes to show -- you can never get too lax in the ICU when you have drips hanging. Glad your patient was ok.

Reminds me of the time one of the excellent nurses on the unit accidently hung a second bag of heparin instead of milrinone. Yep. 2 hep drips, no milrinone running in the PICC. Nobody did the 2 nurse check at shift change because the off going nurse was super nurse (seriously, just an all star on the floor) so it wasn't caught until hours into the night shift. I was brand new on the floor and soooo glad it wasn't me taking care of that patient. After that, nobody would be caught dead not checking a drip at shift change. So the patient was fine and it ended up being an excellent learning experience for eveyone on the unit even though it caused a few heart palpitations in staff that night.

Hoo-Ray,,,thats why its called team work,,,,It takes a village of Nurses to take care of one patient.

Quote from dthomasaHoo-Ray,,,thats why its called team work,,,,It takes a village of Nurses to take care of one patient.

That's the point of bedside report.

Quote from NickiLaughsI went to work the other day, Cardiac ICU. And most of the nurses at my work do not do a bedside report. I often will go check the room just to see what state my patient is in, what drips they are on, etc. I saw that my pt's BP was 80 systolic, curious I looked at the lines, saw Levophed was hanging, and checked the bag...which read Azithromycin. Realized that there was no vasopressor hanging on this ladies BP. So even though I had not received report yet, I hit the hold button, and ordered a bag of levophed stat, grabbed the RN while she was still giving report and showed it to her. This is an excellent nurse, often works charge and resource, has been around for 10 years and it happened to her. Same with the day nurse who is assumed to have hung the medication. And I, the nurse with a year experience, caught it. It was reported and everything is going through proper commands.Just wanted to share, hopefully it will help someone else from making the mistake. I often check all my bags multiple times during a shift, see how I'm doing on fluids and plan to reorder new bags early so I don't run out. But it can happen to anyone.

Quote from missbecky2006 She told me the art line was positional. I go into the room to fix the pump, and the neo was out. Ah hah -- it was a perfectly functional art line after all.

Quote from meandragonbrettI think this has to be the *most* irritating thing I hear on a routine basis. Your aline is likely not positional as it was placed less than 3 hours ago. You're waveform is dampened? Do you even know what that means because you have an adequate sq wave. You have no waveform because you have no blood pressure and you need to change the scale.

Sorry if this is a little bit of a hijack, but what good does changing the scale really do anyway? Other than being able to see the waveform more clearly? I had a pt once , low bp, no uop, etc etc...and the nurse I'm giving report to runs in and changes the scale like it fixed something. I mean, it doesn't change anything for the patient?? I don't really get it. I knew the line was good, good square wave and the waveform itself was ok just small. WHat am I missing?

Quote from highlandlass1592 I can't agree with your statement though regarding the timing of the line..I've had lines put in that dampened within an hour and quickly became positional...