Description of Event or Problem · 1
A PT GOT A 100 FOLD OVERDOSE OF A VASO-ACTIVE DRUG, DUE IN PART TO SOME DESIGN ISSUES WITH THE PUMP. THE BASIC FACTS ARE, CHRONIC RENAL FAILURE PT IN HYPERTENSIVE CRISIS, DOCTOR ORDERED NITROGLYCERIN DRIP AT 5 MCG / MIN TO TRY TO CONTROL THE BP. EXPERIENCED NURSE SET UP THE DRIP, GETS A SCREEN TO CHOOSE MCG/KG/MIN VS MCG/MIN. BUT THERE IS A PARALLAX PROBLEM BECAUSE THE SCREEN IS RECESSED BUT THE BUTTONS ARE ON THE CASE, SO IF YOUR EYE IS ABOVE THE PUMP - TYPICAL, THEY ARE USUALLY MOUNTED ABOUT WAIST HEIGHT -, YOU COULD EASILY MISALIGN THE ARROW AND THE PROMPT AND PRESS THE WRONG ONE. WHICH IS WHAT HAPPENED, SHE INADVERTENTLY CHOSE MCG/KG/MIN WHEN SHE INTENDED TO CHOOSE MCG/MIN. -WE NEVER USE MCG/KG/MIN IN THE ED-. SHE THEN GOT A PROMPT FOR THE PT'S WEIGHT, ENTERED HIS WEIGHT -100 KG-, AND THEN THE DOSE OF 5. THE SCREEN HERE DOES SHOW MCG/KG/MIN, BUT OF COURSE SHE SAW WHAT SHE EXPECTED RATHER THAN WHAT WAS ACTUALLY DISPLAYED. IT THEN COMPLAINED THAT THE DOSE WAS HIGHER THAN THE LIBRARY UPPER LIMIT OF 3 MCG/KG/MIN, WHICH SHE OVER-RODE, BECAUSE WE ALWAYS START AT 5, AND THEN TYPICALLY GO UP RATHER RAPIDLY -EG, INCREASE BY 5 EVERY 5 MIN UNTIL GET TO AROUND 20 OR SO, OR UNTIL THE BP COMES DOWN-, AND THIS PT'S HYPERTENSION WAS QUITE SEVERE. SO, HE GOT 500 MCG/MIN INSTEAD OF 5. COMPLAINED OF A SEVERE HEADACHE, BUT SAID NITRO ALWAYS GIVES HIM HEADACHES. AFTER 15-20 MINS, WE NOTICED THE BAG WAS EMPTY, AND THEN RECONSTRUCTED THE ABOVE.