Medication Error


The FDA reported that between 1993 to 1998 the most common fatal medication errors was related to administration of an improper dose of medicine, accounting for 41% of fatal medication errors. Our hospital policy states that insulin, heparin and lovenox, are the only high risk drugs and have to be double check by another RN. There are several drugs that are either just as high risk or probably more fatal is given incorrectly. At our unit (Coronary Care Unit) we are allowed to mix vasoactive drips, which include but are no limited to, Levophed, Neo-Synephrine, Nipride, and they don’t required to be double checked by another nurse. Why are insulin, heparin and lovenox the only medications required to be double checked under policy? I don’t know, the only reasoning that I can think is that this policy is a hospital wide and mixing vasoactive drips is not so they cannot be included to a “hospital wide” policy. Given the wrong amount of heparin or insulin to anyone can be fatal, but double mixing a Nipride drip or setting the pump wrong with such drugs can also be proven fatal. The steps of making a safer environment for the patient, especially when administering high risk drugs are becoming more widely used but there is still lots of work to be done. In the end most med errors can be prevented when a nurse double checks his/her own work.

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