Pediatric medication errors in the PACU (Post Anesthesia Care Unit), comment

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Medication errors are the fear of many seasoned nurses such as myself. Just today at my work, a nurse gave a TB skin test to a patient instead of a flu vaccine. How could she have done that if she followed the 5 rights that we were all taught in nursing school? I don’t know but I did come across the information discussing the 13 major categories of medication errors that really made me think long and hard! 1. Wrong patient – this is a very important first step to identify the patient correctly. 2. Wrong drug – A busy nurse must very carefully review the drug that they are giving and verify the correctness of the drug on hand. 3. Wrong route- The nurse must assure that the patient is being given the medication in the route specified by the physician’s orders. 4. Wrong time – The nurse must make sure that the medication is being administered at the correct time according to the physician’s orders. 5. Wrong dose – The dosage needs to verified so that the order is administered exactly as prescribed. a. Overdose – The patient is administered more medication than prescribed. b. Underdose – The nurse gives less than the dose ordered to the patient. c. Extra dose – The patient is given a dose other than the prescribed doses for the day. 6. Omitted dose- The patient is not given a dose of the medication that is prescribed for them. 7. Wrong dosage form- The patient is given the dose of medication in a form other than prescribed by their physician. 8. Wrong diluent – The medication was mixed with an incorrect fluid in preparation for administration to the patient. 9. Wrong strength/concentration – The dose was incorrect according to the physician’s orders. 10. Wrong infusion rate – The medication was given at the wrong rate of speed. 11. Wrong technique – An example of this is to crush a pill that should not have been crushed. 12. Deteriorated drug error -Administrating an out-dated medication to the patient. 13. Wrong duration of treatment – Starting or stopping the medication at a time not indicated in the physician’s orders. "According to the 1999 IOM report, among fatal medication errors, the most common types are giving an overdose (36.4%), giving the wrong drug (16.2%), and using the wrong route (9.5%)." Lehne 2009. I believe that as nurses we need to continue to remember the 5 rights and be very aware of the focus it takes to give the correct medications to our patients.

Original Post
September 17, 2009
Title: Pediatric medication errors in the PACU (Post Anesthesia Care Unit), commentThank you for this post… it is a great reminder of the importance of the "5 Rights" of medication administration. Med errors happen more times than we would all like to admit. I have worked in the Neonatal ICU for many years and I will admit I just had a wake-up call. It was an extremely busy day in the unit and I was caring for a set of premature twins with almost identical birth weights, therefore same calculation weights used for dosages. I had a laundry list of meds to give to these patients. After I administered a med and I was tearing the patient label off I realized… the med I just gave was for twin "A" and not "B". It was the Right Medication, the Right Dosage (thankfully being twins of the same size… which does not happen all the time), the Right Route, the Right Time and Right Rationale but not the Right Patient……. the label said "XXXXX, baby-A" and not "XXXXX, baby-B". This was a major wake-up call that thankfully did not cause any harm since both of the patients were to get that exact medication at that exact time but regardless this was a reported Med Error! It really reminded me that no matter how busy you may be….. Take your time when administering medications to your patients… the other tasks can wait!! It can happen to any of us¦ BE CAREFUL!!

Original Post
July 30, 2009
Title: Pediatric medication errors in the PACU (Post Anesthesia Care Unit)

When we, as nurses perform assessments on our patients, in this case, a pediatric patient that will be going for any surgery, we often forget the word beneficence (principal of doing well for our patients) or take it for granted.  We go though the assessment form with the patient and most often the parent assisting, sometimes taking aspects of it as routine or perform a ‘run of the mill assessment’. 

The patient, now has his or her surgery and moves through to the PACU.  We always believe that we will always act in the best interest of our patient, the principal of ‘doing good’.  We always plan on never doing harm to our patients- to do no harm-provide the principal of nonmaleficence. 

‘Medication errors involving pediatric patients in the PACU, may occur as frequently as one in 20 medication orders and more likely to cause harm when compared to medication errors overall.’(AORN 2007, vol 85 page 731)  There have been many instances of late with pediatric medication errors, but the one that is foremost in everyone’s mind is the much published case of the newborn twins of actor Dennis Quaid. A medication(heparin) was administered and the dosage was incorrect.   We as nurses have long been educated and re-educated on the ‘5 rights’ of medication administration.  If we would just take the time to check and re-check the medications, there perhaps would be a decreased number of errors.  Pediatric medication dosages are based on the child’s age, weight and condition. A higher percentage of errors were found of pediatric patients where calculations involving decimals, dosage forms and math related as we have to calculate the proper dosage. Hospitals, pharmacists and nurses are continually trialing and attempting to establish standardized policies, procedures and educating our nurses in the proper handling of our pediatric populations, so errors don’t occur.  Do I think we have the problem solved…no.  But we are well aware of this problem and we have begun the journey to rectify the problems.   I certainly do not want any of our pediatric patients to become statistics and our nurses go through the immense pain and suffering if a negative outcome happens. There are many regulatory bodies that could  get involved.  Not to mention, the family and their worries and concerns for their child, and yes, the lawsuit that may prevail. We must all be very cognizant of not only our pediatric patients, but all our patients.  

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