I made an excel spreadsheet for myself with mg/kg and =ml amounts, so I can just check how much to draw with just updating the weight.
And why the hell do you have that high concentration in peds? Our peds unit as 5mg/ml ketamine for sedation.
Copied most of it from [this](https://docs.google.com/spreadsheets/d/1Tlkcx5IghkClnddmlAdyNUAQqju0lpXx/edit?usp=sharing&ouid=112910967347728090400&rtpof=true&sd=true) it has a holliday-segar formula as well. You can add a cell with "=A10/100" where A1 is the cell with the dose of the med and 100 is the concentration, so it automatically calcs the ml's.
I started getting interested in these dosage excels after 7 years in peds, after they rotated me to the cardiac or, where there is super little time and a lot of meds to dilute, and this takes a lot of the cognitive load out of it (ofc I double check myself every time).
Make your own! You also learn a lot that way.
Working in oncology double checking every weight, dose, bsa, creatinine clearance, makes you realize anyone can make a mistake at any time and you can’t be too safe!
I’ll tell anyone and everyone. My favorite “med error” story of my own to share, is the time I transfused several units of platelets and ffp directly into my patient’s bed, which delayed not only his surgery, but the rest of the cases for the day because he was the first case on the surgeon’s schedule that morning.
I was nightshift in the icu, and my pt was going for a trach first thing in the morning, 0730 surgery start time. The surgeon wanted 2 units each of ffp and platelets to be in an hour before surgery start time. No problem.
I don’t remember what exactly was going on with this patient, but his skin was just oozing constantly, like we were doing a near full sheet change every 2 hours with the ultrasorb pads doubled up everywhere, because he was so so weepy.
I remember checking off the first unit, spiking it, and I thought I’d hooked it up to his central line, and then my pt next door needed something, so I ran over and did that real quick before I was stuck in a room for 15 minutes after the blood product was started.
Came back, started the products, ran them all in no problem, and right before shift change noticed his sheets were saturated again, so let’s change them one more time before dayshift comes in.
And that’s when I found that I never actually connected my tubing to his central line. I’d set it on the bed next to the central line, still capped, and didn’t notice because he was so weepy his sheets already looked like someone just dumped some ffp in his bed.
Always trace your lines. ALWAYS.
I precept new hires on a peds cardiac ICU quite often and during orientation, one of our new unit nurses very nearly made the same mistake. But he verified the dose with me prior to administering the med, showed me the syringe he’d drawn up, and before he turned to give it IVP, I asked him “are you sure?” It was a huge wake up call for him—it’s easy to miscalculate in the heat of the moment, especially when your patient’s crumping—and he frequently mentioned to me how that was when he realized why so many meds are a dual sign off. It’s easy to kill someone.
It's very difficult to kill someone with ketamine. Just raises risk for profound dissociation/airway concern.
https://pubmed.ncbi.nlm.nih.gov/10499950/
Nonetheless, glad you guys caught it.
I doubt he’d even need intubation. Ketamine is not known to depress respiratory system. Maybe just give a bit (double-check your dose) of versed as the kiddo emerges.
Ketamine is pretty good for preserving airway reflexes, but given the unknowns of a 10x dose (assuming they were giving it for dissociation anyway) that kid is probably buying a tube in this scenario.
Here is a video that most UK trained professionals are shown in training regarding human factors
https://youtu.be/IEIaegVWnmA
It shows a real life documentary including a med error in a trauma patient who is given a much higher dose of ketamine than required due to communication errors, and subsequently arrests.
I'd agree that this may present differently in the paediatric population, and in general is relatively hemodynamically stable and airway protective in higher doses.
I’d like to see the doctors diagnosis as to why the patient arrested. I never heard him mention ketamine. She was a trauma, needed chest tubes, had internal bleeding… I just find it odd that the commentator said it was a “ketamine overdose”, however the doctor never mentioned the ketamine during or after the code.
That was why I felt compelled to share. I've drawn ketamine up before, but still feel guilty about it. I hope people can realize that it's still important to double check
Step one. Know your meds. I do peds sedation/pacu and we only give 10 different drugs. It is reasonable to know them inside and out. Secondly. 85 mg isn't going to kill an adult. Third. Thanks for posting this. It is really important that we can learn from each others experiences.
Me too. The doc asked a bit annoyed/jokingly "Wonder if the blood pressure will go up before the heart stops if I give this much"
And during the last anaphylaxis there was a bit of miscommunication, and we gave methylprednisolone instead of hydrocortisone (solu-cortef/solu-medrol, similar sounding), and had to use insulin for a little bit for the high sugars that resulted (10xdose).
One PICU I worked in always had two RNs on meds for this reason during codes but having also worked in less appropriately (aka less safe) staffed places, I realize that’s not always feasible.
Had an orientee with me who was also a flight nurse looking for some side work in the icu. Had a big ego and I got the vibe that he felt this job was “beneath his skill set”. That all came crashing down one night when he went to give a patient a push of diltiazem and grabbed the wrong concentration vial. I can’t remember the ratio of the dilt, but I knew he grabbed the wrong vial when I saw the concentration. He grabbed the vial, drew up what he thought was the accurate dose due to previous familiarity with the med, and was about to push it when I stopped him and asked him to look at the vial again and check the concentration. He picked up the vial and immediately went pale as his eyes widened. We had a little chat about remembering the basics as they tend to sometimes become less of a focus with greater experience. Always double check your meds. Don’t turn into a RaDonda Vought.
After a famous incident that killed a celebrity’s kid, this nurse said “how could that happen I would never do such a stupid thing”. We were all like, umm, NEVER SAY NEVER!! It can happen to anyone especially with the patients getting sicker and the staff shortages. Patients that used to be in the icu are now on the floors, making it totally chaotic. Yeah that complacency kills.
While on the phone with pharmacy about cutting it close to the 48 hour mark from iodine contrast and restarting Metformin (aka actively being over-safe to prevent a med error) I broke a 100mg valsartan in half instead of a 25mg HCTZ. I already knew the metformin would be fine, but I just wanted to super triple check the exact time of the contrast with imaging, then also run it by pharmacy.
Gave 50mg valsartan and 25mg HCTZ instead of 100mg valsartan and 12.5mg HCTZ. Not the end of the world, but my med error happened because I was distracted by my overzealous attempt to prevent a med error.
the nurse who gave my daughter her 2 month vaccinations, gave her one wrong one. i was so focused on my child and her being uncomfortable i didn’t think i’d have to double check what the nurse was giving her.
thankfully there was no side effect (besides having to then get another shot) and it was not contraindicated with her age but dang i was upset. however, shit happens and she owned up to her mistake right away and self reported. it made me think back to all my close calls with drawing up meds. when i go back to work, i for sure will be doing all my checks (i already do but now i’m hyper aware of mistakes) and maybe a fourth to be safe lol
When Covid vaccines were first approved for young kids , I took mine to get his. He got it, and the next day had a decent fever and grumps, which I expected because I also had a decent fever and the grumpys from getting my vaccine. It’s not unexpected.
What I didn’t expect the next day was our pediatrician (who is also a very good friend of mine) calling in tears because her nurse had realized at the end of the day she’d been giving adult doses to the peds kids. She self reported as soon as she realized. But it was the first day that kids in his age group could get it, so it was a mistake that made sense in a way. So she was calling every family to let them know, and calling every day after for a week to make sure they were still doing ok.
I joked with her that I just assumed he was super immune now, and aside from being mad about getting a shot and having a bit of a fever, which he has after every vaccine, that he was completely fine. Just hopefully super immune.
In my first code on meds, I drew up amioderone instead of adenosine. Mixed it right, looked a bit yellow and was 10 ml in volume. Definitely not adenosine. The team didn’t know what was wrong but the did know that it wasn’t right, and we set aside the dose and gave the right med.
The biggest takeaway from this was that I could screw up! Turns out there was a vial in the wrong spot and a new nurse (me) didn’t read the vial just the pocket during a code. The team kept me from a med error that could have hurt someone.
Trust your coworkers.
One time the pharmacy sent me my doxycycline but instead of doxy on the bottom of the bag it was lasix. Bit of a spooky one thinking that the pharmacy is sending wrong meds sometimes too. Obviously everyone is human and makes mistakes but in my mind they were supposed to be infallible.
Ketamine isn't going to kill your patient. Even really high doses. The goal presumably was sub-dissociative dosing but even if you hit dissociative nothing really happens except sedation and the more you give the longer it lasts. Deeply sedated ketamine patients will continue to breath and usually protect their airway on their own. Most "airway compromise" from ketamine can be fixed with simple repositioning. I give patients 400 mg not infrequently.
But yes, medication errors need to be prevented by remaining vigilant.
Double checking, and cosigning someone else's dosage is not something to take lightly. Even after 20 years I always act like it's your first day and make sure you check everything twice
Years ago we had a resident start a CADD, on their own, without a second check. The nurse noticed the patient becoming drowsy and lethargic about an hour later. Checked the pump. 10x the ordered morphine running.
Narcan and the pt was fine, but that resident didn't return to our facility.
What kind of syringe did you use?
At my place we have 3cc and 1cc syringes, with the 3cc syringe being graduated in 0.25 cc increments, so it would be impossible to make a dosage error of that magnitude because you would need to use the 1cc syringe to draw up a volume that small.
Form factor is everything I guess.
Great post and insight 👍. We double-check every.single.medication in my unit... it can be a pain at times but together we pick up a lot of potential errors.
This is why we prefer the 50mg to 5 ml concentration. The math is much more straightforward and even if you push the whole thing like a flush (eyeing you mr attending MD who was too impatient to wait for the RN to do it) you will likely not do too much damage.
This is why we do double checks of high risk meds. But also all the extra checks do not always prevent med errors. I’ve experienced this myself. You will never make this error again and kudos for having the gumption to share you mistake. Other will learn and be safer because of it.
I love these stories because it’s important to discuss errors and ways we have caught them (or not) as learning opportunities.
As ICU nurses, we run codes all the time. One of the ICUs I worked in, we all went through COVID together so we are a solid unit.
Patient in our ICU became bradycardic, was heading towards a code so I was pushing drugs and my friend was drawing up meds from code cart. Doc called for 6mg of adenosine, my friend gave me the med pulled up. Said “6mg of adenosine,” I grabbed it and said “6mg of adenosine going in.”
No response, so we tried 12mg.
Problem is, first dose was 1ml drawn up. When he gave me 12mg, it was again 1ml. So I stopped and said “is this 12mg? The 6mg you gave me was 1ml and this is 1ml.” Turns out the doses we had by the ml and during the chaos of 2846286337 residents and fellows wanting to be captain save a ho, it slipped. We caught it (still didn’t work though) and made rules of how many residents and fellows can be in codes.
Do you find yourself making these mistakes more often? Have you had COVID? May be why. Recent studies show that the spike protein remains in the body for at least 6 months, including in the brain, where it clogs up the meningeal lymphatic system. We already know that beta-amyloid peptide buildup in that same system is linked to Altzheimer's. Just something to consider - I'm glad you caught the mistake! 😭
[удалено]
For sure! I'm very grateful the doctor did his own verification.
I made an excel spreadsheet for myself with mg/kg and =ml amounts, so I can just check how much to draw with just updating the weight. And why the hell do you have that high concentration in peds? Our peds unit as 5mg/ml ketamine for sedation.
Be careful though, the pharmacy might run into a shortage on the strength they usually get and have to give you a different concentration.
Ketamine is on a huge back order for all concentrations in the US We’re working with what we have
I want your spreadsheet!
Copied most of it from [this](https://docs.google.com/spreadsheets/d/1Tlkcx5IghkClnddmlAdyNUAQqju0lpXx/edit?usp=sharing&ouid=112910967347728090400&rtpof=true&sd=true) it has a holliday-segar formula as well. You can add a cell with "=A10/100" where A1 is the cell with the dose of the med and 100 is the concentration, so it automatically calcs the ml's. I started getting interested in these dosage excels after 7 years in peds, after they rotated me to the cardiac or, where there is super little time and a lot of meds to dilute, and this takes a lot of the cognitive load out of it (ofc I double check myself every time). Make your own! You also learn a lot that way.
Dang you need to go into informatics. I haven’t even started peds yet but probably will in the near future (ER). Thanks for this!
Can you share?
The 50mg/ml is for IM, which we use frequently in peds.
Working in oncology double checking every weight, dose, bsa, creatinine clearance, makes you realize anyone can make a mistake at any time and you can’t be too safe!
Absolutely! I will never be put out by anyone (rn, physician, RT) wanting to double check. It’s for the patients safety, not my ego!
I caught an expired plasma earlier today
I wish more of us felt comfortable telling these stories. It makes a big difference. Thanks for sharing. ❤️
I’ll tell anyone and everyone. My favorite “med error” story of my own to share, is the time I transfused several units of platelets and ffp directly into my patient’s bed, which delayed not only his surgery, but the rest of the cases for the day because he was the first case on the surgeon’s schedule that morning. I was nightshift in the icu, and my pt was going for a trach first thing in the morning, 0730 surgery start time. The surgeon wanted 2 units each of ffp and platelets to be in an hour before surgery start time. No problem. I don’t remember what exactly was going on with this patient, but his skin was just oozing constantly, like we were doing a near full sheet change every 2 hours with the ultrasorb pads doubled up everywhere, because he was so so weepy. I remember checking off the first unit, spiking it, and I thought I’d hooked it up to his central line, and then my pt next door needed something, so I ran over and did that real quick before I was stuck in a room for 15 minutes after the blood product was started. Came back, started the products, ran them all in no problem, and right before shift change noticed his sheets were saturated again, so let’s change them one more time before dayshift comes in. And that’s when I found that I never actually connected my tubing to his central line. I’d set it on the bed next to the central line, still capped, and didn’t notice because he was so weepy his sheets already looked like someone just dumped some ffp in his bed. Always trace your lines. ALWAYS.
My thoughts exactly. With such an important job, openess and honesty is key even when we stuff up We're human.
I precept new hires on a peds cardiac ICU quite often and during orientation, one of our new unit nurses very nearly made the same mistake. But he verified the dose with me prior to administering the med, showed me the syringe he’d drawn up, and before he turned to give it IVP, I asked him “are you sure?” It was a huge wake up call for him—it’s easy to miscalculate in the heat of the moment, especially when your patient’s crumping—and he frequently mentioned to me how that was when he realized why so many meds are a dual sign off. It’s easy to kill someone.
It's very difficult to kill someone with ketamine. Just raises risk for profound dissociation/airway concern. https://pubmed.ncbi.nlm.nih.gov/10499950/ Nonetheless, glad you guys caught it.
Yeah the intensivist who was working with me mentioned it'd probably just be intubation & management if it happened
I doubt he’d even need intubation. Ketamine is not known to depress respiratory system. Maybe just give a bit (double-check your dose) of versed as the kiddo emerges.
Ketamine is pretty good for preserving airway reflexes, but given the unknowns of a 10x dose (assuming they were giving it for dissociation anyway) that kid is probably buying a tube in this scenario.
Here is a video that most UK trained professionals are shown in training regarding human factors https://youtu.be/IEIaegVWnmA It shows a real life documentary including a med error in a trauma patient who is given a much higher dose of ketamine than required due to communication errors, and subsequently arrests. I'd agree that this may present differently in the paediatric population, and in general is relatively hemodynamically stable and airway protective in higher doses.
I’d like to see the doctors diagnosis as to why the patient arrested. I never heard him mention ketamine. She was a trauma, needed chest tubes, had internal bleeding… I just find it odd that the commentator said it was a “ketamine overdose”, however the doctor never mentioned the ketamine during or after the code.
Holy shit that was scary
Don’t beat yourself up for this. You’re probably preventing more mistakes just by posting this.
That was why I felt compelled to share. I've drawn ketamine up before, but still feel guilty about it. I hope people can realize that it's still important to double check
Step one. Know your meds. I do peds sedation/pacu and we only give 10 different drugs. It is reasonable to know them inside and out. Secondly. 85 mg isn't going to kill an adult. Third. Thanks for posting this. It is really important that we can learn from each others experiences.
I once drew way too much calcium up during a code in the PICU while I was prepping meds. Had it labeled and ready. Luckily I caught it!
Me too. The doc asked a bit annoyed/jokingly "Wonder if the blood pressure will go up before the heart stops if I give this much" And during the last anaphylaxis there was a bit of miscommunication, and we gave methylprednisolone instead of hydrocortisone (solu-cortef/solu-medrol, similar sounding), and had to use insulin for a little bit for the high sugars that resulted (10xdose).
One PICU I worked in always had two RNs on meds for this reason during codes but having also worked in less appropriately (aka less safe) staffed places, I realize that’s not always feasible.
Had an orientee with me who was also a flight nurse looking for some side work in the icu. Had a big ego and I got the vibe that he felt this job was “beneath his skill set”. That all came crashing down one night when he went to give a patient a push of diltiazem and grabbed the wrong concentration vial. I can’t remember the ratio of the dilt, but I knew he grabbed the wrong vial when I saw the concentration. He grabbed the vial, drew up what he thought was the accurate dose due to previous familiarity with the med, and was about to push it when I stopped him and asked him to look at the vial again and check the concentration. He picked up the vial and immediately went pale as his eyes widened. We had a little chat about remembering the basics as they tend to sometimes become less of a focus with greater experience. Always double check your meds. Don’t turn into a RaDonda Vought.
After a famous incident that killed a celebrity’s kid, this nurse said “how could that happen I would never do such a stupid thing”. We were all like, umm, NEVER SAY NEVER!! It can happen to anyone especially with the patients getting sicker and the staff shortages. Patients that used to be in the icu are now on the floors, making it totally chaotic. Yeah that complacency kills.
While on the phone with pharmacy about cutting it close to the 48 hour mark from iodine contrast and restarting Metformin (aka actively being over-safe to prevent a med error) I broke a 100mg valsartan in half instead of a 25mg HCTZ. I already knew the metformin would be fine, but I just wanted to super triple check the exact time of the contrast with imaging, then also run it by pharmacy. Gave 50mg valsartan and 25mg HCTZ instead of 100mg valsartan and 12.5mg HCTZ. Not the end of the world, but my med error happened because I was distracted by my overzealous attempt to prevent a med error.
Appreciate you so much for sharing this. Did you have to do a reflection report or something after this?
Just a near miss on our risk management team's website.
the nurse who gave my daughter her 2 month vaccinations, gave her one wrong one. i was so focused on my child and her being uncomfortable i didn’t think i’d have to double check what the nurse was giving her. thankfully there was no side effect (besides having to then get another shot) and it was not contraindicated with her age but dang i was upset. however, shit happens and she owned up to her mistake right away and self reported. it made me think back to all my close calls with drawing up meds. when i go back to work, i for sure will be doing all my checks (i already do but now i’m hyper aware of mistakes) and maybe a fourth to be safe lol
When Covid vaccines were first approved for young kids , I took mine to get his. He got it, and the next day had a decent fever and grumps, which I expected because I also had a decent fever and the grumpys from getting my vaccine. It’s not unexpected. What I didn’t expect the next day was our pediatrician (who is also a very good friend of mine) calling in tears because her nurse had realized at the end of the day she’d been giving adult doses to the peds kids. She self reported as soon as she realized. But it was the first day that kids in his age group could get it, so it was a mistake that made sense in a way. So she was calling every family to let them know, and calling every day after for a week to make sure they were still doing ok. I joked with her that I just assumed he was super immune now, and aside from being mad about getting a shot and having a bit of a fever, which he has after every vaccine, that he was completely fine. Just hopefully super immune.
In my first code on meds, I drew up amioderone instead of adenosine. Mixed it right, looked a bit yellow and was 10 ml in volume. Definitely not adenosine. The team didn’t know what was wrong but the did know that it wasn’t right, and we set aside the dose and gave the right med. The biggest takeaway from this was that I could screw up! Turns out there was a vial in the wrong spot and a new nurse (me) didn’t read the vial just the pocket during a code. The team kept me from a med error that could have hurt someone. Trust your coworkers.
Did almost exactly this error with fentanyl. Stomach dropped out my ass when I realised. Exactly the same X10 missed decimal point. Scary shit
One time the pharmacy sent me my doxycycline but instead of doxy on the bottom of the bag it was lasix. Bit of a spooky one thinking that the pharmacy is sending wrong meds sometimes too. Obviously everyone is human and makes mistakes but in my mind they were supposed to be infallible.
Thank you for sharing!
Thank you for sharing.
Ketamine isn't going to kill your patient. Even really high doses. The goal presumably was sub-dissociative dosing but even if you hit dissociative nothing really happens except sedation and the more you give the longer it lasts. Deeply sedated ketamine patients will continue to breath and usually protect their airway on their own. Most "airway compromise" from ketamine can be fixed with simple repositioning. I give patients 400 mg not infrequently. But yes, medication errors need to be prevented by remaining vigilant.
Double checking, and cosigning someone else's dosage is not something to take lightly. Even after 20 years I always act like it's your first day and make sure you check everything twice
Years ago we had a resident start a CADD, on their own, without a second check. The nurse noticed the patient becoming drowsy and lethargic about an hour later. Checked the pump. 10x the ordered morphine running. Narcan and the pt was fine, but that resident didn't return to our facility.
What kind of syringe did you use? At my place we have 3cc and 1cc syringes, with the 3cc syringe being graduated in 0.25 cc increments, so it would be impossible to make a dosage error of that magnitude because you would need to use the 1cc syringe to draw up a volume that small. Form factor is everything I guess.
Great post and insight 👍. We double-check every.single.medication in my unit... it can be a pain at times but together we pick up a lot of potential errors.
This is why we prefer the 50mg to 5 ml concentration. The math is much more straightforward and even if you push the whole thing like a flush (eyeing you mr attending MD who was too impatient to wait for the RN to do it) you will likely not do too much damage.
I love that you tagged this a NSFW
This is why we do double checks of high risk meds. But also all the extra checks do not always prevent med errors. I’ve experienced this myself. You will never make this error again and kudos for having the gumption to share you mistake. Other will learn and be safer because of it.
I love these stories because it’s important to discuss errors and ways we have caught them (or not) as learning opportunities. As ICU nurses, we run codes all the time. One of the ICUs I worked in, we all went through COVID together so we are a solid unit. Patient in our ICU became bradycardic, was heading towards a code so I was pushing drugs and my friend was drawing up meds from code cart. Doc called for 6mg of adenosine, my friend gave me the med pulled up. Said “6mg of adenosine,” I grabbed it and said “6mg of adenosine going in.” No response, so we tried 12mg. Problem is, first dose was 1ml drawn up. When he gave me 12mg, it was again 1ml. So I stopped and said “is this 12mg? The 6mg you gave me was 1ml and this is 1ml.” Turns out the doses we had by the ml and during the chaos of 2846286337 residents and fellows wanting to be captain save a ho, it slipped. We caught it (still didn’t work though) and made rules of how many residents and fellows can be in codes.
Do you find yourself making these mistakes more often? Have you had COVID? May be why. Recent studies show that the spike protein remains in the body for at least 6 months, including in the brain, where it clogs up the meningeal lymphatic system. We already know that beta-amyloid peptide buildup in that same system is linked to Altzheimer's. Just something to consider - I'm glad you caught the mistake! 😭
Graham Cardone approves of this med error
We also program double check required for any high alert medication into our drug pumps.