Monday, February 3, 2014



Patient had a seizure.  Broke his face open hitting the floor and then broke it some more while the seizure continued.  But this posting is not about the lack of help I got from my staff, such as when I asked two attendants standing nearby to get me sheets and blankets.  Three times.  Finally one of them said, "Me?  He is not even my patient!"

This post is about how the error happened that led to the seizure.

I'm giving report to the ED.  Yes, history of seizures.  What medications does he take for seizures?  Dilantin.  Nope.  Was discontinued and started on Depakote.  500 mg twice a day to 1000 mg twice a day to 2000 mg.  Oops.  Was discontinued yesterday and started on lithium for bipolar.

A review of the chart showed that the Depakote was originally ordered for seizures by a neurologist.  A psychiatrist increased the dosing and wrote the indication as bipolar and not seizure disorder.  When the patient's moods were still cycling daily, the psychiatrist discontinued Depakote- clearly not working for the bipolar disorder- and tried Lithium- which is of no benefit in preventing seizures.  Suddenly withdrawing the Depakote likely induced the seizure.

How could this have happened?  Various higher people wanted to know.

Well, let's see.  Instead of allowing me to concentrate on medications and physical assessments, they have me serving breakfast and lunch because the dietary department is short-staffed; yet I highly doubt that they have fewer than one person working, which is the number of people working on my ward.  I have to do the filing in the paper charts because it's too much for the clerk to have to file in addition to everything else she does (which is . . .).  The medical doctors work overnight, take off in the morning, and then return at 2 pm and write a flurry of orders right before my shift ends.  I have too many doctors descending upon me at once and the incoming shift does not have to take off orders written on my shift- and I do not get paid for staying later because "there is no reason why you cannot complete your assigned tasks in the allotted time."  I am the only permanent nurse on the ward and I work with a floater unfamiliar with the ward and disinterested in working at all.  The attendants will not perform the simplest tasks, insisting that it is so easy that I can do it myself instead of "expecting everyone else to do my job for me."  The supervisor of the day marches in, oblivious to what I am doing and the whirlwind of chaos around me, and launches into a diatribe about how so-and-so is upset and it's all my fault, blah blah blah.

And that is the story behind that error.

Coincidentally, I remember this patient during his last stay because of another error.  He is allergic to a few drugs.  The practice at my hospital is to not fill out any allergy information on the chart, the order sheets, or the medication administration record.  I always fill it out, but most people don't, and I end up filling it in for other nurses and doctors when my name has to go on the page for some reason.  The patient started acting very nasty for a few days.  I reviewed the chart and realized that the psychiatrist had started him on a medication that was listed as an allergy.  I called the doctor and discontinued the medication and the patient cleared up.  The error was not intercepted by any safeguard in place:  the nurse taking off the order, the nurse reviewing the order on the 24 hour chart check, the pharmacy, and the nurse giving the medication.  As far as I know, the error was not caught on any subsequent chart audit.

For those of you who have your wits about you, pay very careful attention to the medications you receive.

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