Nursing: Confidentially

Batteries included

MEDICATION ERROR

Russian roulette

As a nursing student, I was caring for 47-year-old Mr. Dean, who was using a transcutaneous electrical nerve stimulator (TENS) unit for postsurgery pain.

When I went to check on Mr. Dean, he complained that the TENS unit wasn't working. Examining it, I discovered that the power source light was off; the batteries were dead. Simple to fix, I thought.

As soon as I inserted new batteries, Mr. Dean clutched his abdomen and cried out in pain. I immediately took the batteries out and Mr. Dean relaxed. Only then did I notice that the unit's dial had been turned to the highest setting.

Although Mr. Dean wasn't seriously harmed, this mishap taught me a valuable lesson: Before I turn on any equipment, I check the settings. Long ago, I was working in a hectic medical oncology unit. We mixed our own medications at the time, so medication trays containing numerous syringes were common. To identify the medications, we used cards with holes, which we slipped the syringes into.

I entered Mr. Duffy's room with two syringes: one with medication to add to an I.V. bag and the other with 0.9% sodium chloride to flush the line. As I picked them up, the card slid off and fell. I looked at the two syringes, which contained the same amount of fluid. I took the one that I was sure was 0.9% sodium chloride and began to slowly flush Mr. Duffy's catheter. Instantly he yelled in pain and grabbed his arm. I stopped flushing immediately and withdrew fluid from the line. I discarded both syringes and administered a new 0.9% sodium chloride flush. Mr. Duffy reported that the pain subsided.

Although my patient was okay, I never relied on the medication card again: From then on, I took the time to clearly label each syringe to prevent another error.

Have you learned from a mistake you made in nursing? If so, please tell us about it...in strictest confidence...and perhaps share it with other nurses on these pages. Details will be altered to ensure anonymity. And we'll pay $50 for it. Address letters to: Confidentially, Nursing99, 1111 Bethlehem Pike, P.O. Box 908, Springhouse, PA 19477. Please include a self-- addressed, stamped envelope. Or, send your item via E-mail to: confidentially@springnet.com.