Error Number 157. Failing to observe dose precautions of analgesics for patients recovering from anesthetics

When Mrs. Roberts, who'd had a general anesthetic for a hysterectomy, was returned to her room, she began complaining of pain. In the recovery room, her surgeon had ordered meperidene hydrochloride (Demerol) 75 mg intramuscularly every 4 hours, p.r.n., pain, so the nurse gave her the ordered dose. Soon Mrs. Roberts became acutely hypotensive. Her surgeon, checking her chart, discovered that fentanyl citrate/droperidol (Innovar) had been administered to Mrs. Roberts while she was in surgery.

As you know, when the combination analgesic/neuroleptic, Innovar, is given during surgery, subsequent doses of narcotic analgesic drugs should be reduced, in some cases to as low as one third the usual dose. This precaution is necessary to avoid potentiating Innovar's respiratory depressant and hypotensive actions. Usually, the precaution must be observed for 4 to 6 hours after administration of the Innovar.

This precaution, though well known, is sometimes ignored because the doctor ordering the drugs simply forgets it, doesn't think the precaution is necessary, or doesn't know that the patient has received Innovar. Still, since the nurse giving the drugs shares the responsibility, she should question such orders .

Complications like those in Mrs. Roberts' case can be avoided by always following this procedure:

1. When the patient is given Innovar, the person administering the drug should immediately affix the label (which is coated with a reusable adhesive and comes as part of the drug package) to the metal front of the patient's chart.
2. The doctor ordering the Innovar should note on the label the period for which the precautions are in effect. If a narcotic analgesic is ordered later, this order should observe the reduction in dose for the time period.
3. When the patient and chart arrive on the nursing floor, the nurse or ward clerk noting the orders should peel the Innovar label off the chart and reaffix it directly on the patient's medication administration record. Also, the order as written by the doctor should be noted.

This procedure provides double insurance that the precautions will be followed-the initial order shows the reduced dosage and the sticker is a highly visible reminder.