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A patient was brought to the recovery room after undergoing a carotid endarterectomy. Her arterial line showed a blood pressure of 190/100 and rising. So the recovery room doctor ordered a stat I.V. infusion of the potent antihypertensive sodium nitroprusside (Nipride).
The nurse, who was new to the recovery room, rushed to the medication area to prepare the admixture. She carefully reconstituted the Nipride and labeled the container of D5 W to show what she was adding to it. Then she brought the container back and gave it to the doctor, who started the infusion at a rate of 1 mcg/ kg/minute.
The patient's blood pressure continued to rise. The doctor gradually increased the infusion rate to 10 mcg/kg/minute-but the blood pressure kept rising. The doctor checked the label to see if the nurse might have added the wrong amount of Nipride to the solution. But it stated the correct amount: 50 mg/250 ml D5W.
Just as the patient's blood pressure reached 210/11 0, the I.V. container ran dry and the nurse went to prepare another admixture. To her horror, she discovered the syringe with the Nipride lying on the medication counter.
In her rush to prepare the first admixture, the nurse had forgotten to add the drug. She had reconstituted it in the syringe but then laid the syringe aside while she wrote out and applied the label to the container.
Flustered, the nurse ran back and told the doctor about her error. As she was doing so, another nurse quickly prepared the correct admixture and started the infusion at the original rate of 1 mcglkg/minute. Within minutes, the patient's blood pressure started to drop.
Four lessons can be learned from this incident that will help prevent a similar error.
First and most important, always prepare an I.V. admixture before you label the container. Then check the emptied additive container to make sure you've added the correct drug and amount to the I.V. solution.
Second, don't let a crisis unnerve you or allow another staff member to rush you into cutting comers. Take time to pay close attention to what you're doing, especially if you have a lot of distractions.
Third, see that someone who's familiar with procedures is assigned to supervise an inexperienced nurse during a crisis. Re-member, she's likely to be doubly nervous, have an incomplete knowledge base, and be more apt to make an error.
Finally, if you discover that you have made an error, report it immediately. If this nurse hadn't told the doctor of her error, he might have ordered the second Nipride infusion to be given at 10 mcg/kg/minute. This would undoubtedly have caused severe hypotension