Medication Error In Hospital!

[Lisa in Katy]

The error I experienced after surgery was initiated because the Morphine they were giving me for the pain made me throw up. So, my surgeon (over the phone) told them to give me Phenergan (for the nausea) and the nurse wrote it as discontinue Morphine and give Phenergan. This started at about 7:00 p.m. on the first evening after surgery, and when they would ask me my level of pain on a scale of 1-10, I would say 100. So, the nurse would say "Well, we just gave you Phenergan, so you can't have another dose until...." From having a child with a bad stomach virus, I knew that Phenergan was for nausea, and I told the nurse this. It does have a slight sedative effect, but doesn't do anything for pain. She kept insisting that it was for the pain. My blood pressure was extremely high, and the doctor later said it was a miracle that it hadn't sent my heart into orbit. Needless to say, in the morning when the Nurse Anesthetist came by to see what they could do about my pain (that had now been untreated for about 12 hours), I told her that all they were giving me was Phenergan, and she solved the problem immediately. My doctor was irate that they hadn't called him. The hospital sent me flowers and wiped away my portion of the bill. The nurse apologized to me, but I refused to accept it. I just said, "I tried to tell you the problem, but you refused to listen, so now I refuse to listen to you." She was later fired. It made me very sad to think that if I had been a less healthy or more elderly person, I probably wouldn't have survived this mistake. This was also a very good hospital and I was even considered a VIP, but all it takes is one person in a hurry to mess the whole thing up.

Hope your husband is home soon so it won't be necessary for you to depend on a third party to divvy out his meds. It's so much easier when we are in charge of ourselves!

 

[Mb]

Thank you all for your input. It is good to know that it does happen elsewhere. I am kicking myself that I didn't have a better heads up., But frankly, I am a bit tired, and after ten days of watching them give him meds three to four times a day, sometimes even more, I think I got confused myself.

Now....his INR yesterday as at 2.4. This morning, 2.0. They gave him another lovenox shot, and 15 mg. of coumaden. I can't wait to see what the INR is in the morning. Hopefully, if it is in range, they will get him out, and like Nancy says, I'll be driving him all over the place every day to get the finger stick. Ugh.

Again, thank you to everyone for your input.

Marybeth

 

[Gnusgal]

The error I experienced after surgery was initiated because the Morphine they were giving me for the pain made me throw up. So, my surgeon (over the phone) told them to give me Phenergan (for the nausea) and the nurse wrote it as discontinue Morphine and give Phenergan. This started at about 7:00 p.m. on the first evening after surgery, and when they would ask me my level of pain on a scale of 1-10, I would say 100. So, the nurse would say "Well, we just gave you Phenergan, so you can't have another dose until...." From having a child with a bad stomach virus, I knew that Phenergan was for nausea, and I told the nurse this. It does have a slight sedative effect, but doesn't do anything for pain. She kept insisting that it was for the pain.

Did this woman go to nursing school?! How could she NOT know that phenergan was not a pain med. They're expected to know almost as much about meds as docs (at least these days). I can understand double dosing because of a clerical error WAY more than being completely stupid!!! Sorry, that story really flipped me out.

 

[Nancy]

Marybeth-

It is surely not up to you to keep track of Wayne's meds while in the hospital. Things get so turned around sometimes when we, as advocates for our loved ones, care more than those who are taking care of them in the "place of healing". It is the HOSPITAL personnel, doctors, nurses, pharmacists, et al who get PAID and very well, to do this kind of thing. When they don't do their job, it can make us feel like we failed. But THEY failed.

I once brought a large picture (8 X 10) of Joe, when he was healthy, into the ICU and pinned it up on the wall, and wrote on it, "This is Joe Pennell, he is a human being". The nurse looked at it and said, "you know, some people will get offended by that"

You are Wayne's best buddy and a great caregiver. Get after those who are slugs, and see if you can, as the saying goes, "grease their skids" on their way out.

Marybeth, try to get a hospital lab to come to the house to do the labs at home, if you can. We were able to do that from time to time. Wayne has been through too much right now to be getting into and out of cars every other day. Your doctor can help to set that up.

You both have been through stressful times and need some peace.

 

[SaraC]

Medication errors

Medication errors

Hello,
As others have stated it is important to speak up if you think an error has been made or is about to be made. In a hospital, there is usually a patient advocate or House Supervisor present that you can request if the charge nurse is not being helpful or is too busy.

When a problem occurs, health care professionals appreciate hearing about it right away before anger and resentment set in; a collaborative atmosphere is best in order to solve the problem. Many hospitals are going to a "bedside medication verification" or BMV system that greatly reduces the chances of getting an incorrect medication or dose. So hopefully you are seeing this in some hospitals.

Another thing you shouldn't be afraid of asking is to make sure the staff is washing their hands between patients. If the hospital is accredited by the Joint Commission (or "JCAHO"; which most are) they have a campaign to "Speak Up" for handwashing or potential problems so this shouldn't come as a surprise to well informed health care professionals. Try it once- ask your doctor if he/she just washed his/her hands if you aren't sure!

Another website you may want to look at is the Agency for Healthcare Research and Quality (AHRQ); this link takes you within the website to a page titled "Five steps to safer Health Care" at http://www.ahrq.gov/consumer/5steps.htm for proactive tips.
Take care everyone...

 

[geebee]

When I was in the hospital in November, every time I was given a pill, a computerized medicine cart was wheeled in to the room. The nurse checked the computer, the pill package was scanned, my ID bracelet was scanned and an entry was made into the computer. Even so, I checked every pill before I put it in my mouth. I even refused one medication and was not given any hassle about it. It seemed like a pretty good system and, hopefully, will be everywhere soon. I am sure there could still be ways to mess this up but it is definitely going in the right direction.

 

[Karlynn]

I'm just wondering why they are giving him Lovenox with an INR of 2.4 and 2.0? Is this usual for someone with a new valve?

He got 30 mg on Tuesday, so it should just be showing up in the INR now. I'm going to be really curious as to what his INR is Friday morning.

Hang in there MaryBeth. You are doing a great job!

 

[sue943]

All very scary stuff. A friend of mine had her father killed in hospital with the wrong medication, a nurse gave him insulin due for the person in the next bed. Her sister witnessed it and even challenged why he was being given medication. She also had the presence of mind to pick up the empty vial when all hell let loose. He died and the family received no compensation, they were told he proabably would have died anyway! He had gone in with 'flu and was only in there as he tended to have chest problems.

I am used to two nurses being at the bedside, checking the bracelet for your name, and then administering drugs and recording it.

 

[Magic8Ball]

Now....his INR yesterday as at 2.4. This morning, 2.0. They gave him another lovenox shot, and 15 mg. of coumaden.

? sorry lost track, does this mean that yesterday they gave him 30mg and today they have continued and given him another 15mg?

If so get him out of there quick, they have no bloody idea what they are doing...

Yesterdays 30 wont make a change in his inr for at least 2-3 days, i'd expect it to make a big difference as that is nearly a weeks dose for an average joe in a single day...

When they were 'loading' be post surgery the largest dose in a single day i got was 7mg.....i'm now on 33mg a week.

Id start making the biggest stink possible and get someone totally independant in to review what has been done and make reccomendations.

Really sorry you are going through this.