| Contents | Previous | Next |
A doctor ordered hydromorphone (Dilaudid), 2 mg subcutaneously, every 3 hours for a woman who had severe back pain from metastatic cancer. She was given an injection at 1 p.m., then an hour later was sent for her daily radiation treatment.
When she returned to her room at 3:50, she said she was in pain. Because her next dose of Dilaudid was scheduled for 4 p. m. and her vital signs were stable, her nurse gave the injection.
At 4:30, the patient's sister arrived to visit. Almost immediately, she called the nurse into the room, saying that her sister wouldn't respond. The nurse quickly checked the patient's vital signs and found her respiratory rate had dropped from 18 to 10 and her diastolic blood pressure had dropped by 15 mm Hg.
The nurse called the doctor, explained the situation, and added that the patient had last received Dilaudid at 4 p.m. But the doctor explained that the radiology nurse had called him at 3 p.m. to say the patient was in severe pain and couldn't withstand further treatment. So he'd ordered it given an hour early.
The doctor ordered 1 mg of naloxone (Narcan), which quickly counteracted Dilaudid's effects.
This error resulted from a combination of inadequate charting and lack of communication. Although the radiology nurse had documented the 3 p.m. dose in the nurses' notes, she couldn't write it in the patient's medication administration record (MAR) because this record wasn't in the chart. But she could have alerted the patient's nurses by calling the unit or placing a note on front of the chart. When the patient returned to her room, her nurse checked the MAR but didn't think to check the nurses' notes or doctor's order sheet before giving the 4 p.m. dose.
Send a patient's MAR with him when he goes to other areas for treatment or tests. And make it a habit to read the nurses' notes and progress notes when he returns.