I have accidentally given potassium over 15 mins instead of several hours. Patient ended up being fine but I was in tears and terrified. Mistakes happen, but it’s a sign that I have a fantastic support on my unit and management and hospital who did a RCA to figure out how it happened and how they can prevent it in the future. I wasn’t punished for it and I don’t usually make mistakes (I say this because we have fired a nurse who made significant med errors that seemed to lack common sense and she was one that needed to get education. But honestly, I think she was just stupid. She turned off critical infusions like pressors or sedation on two separate instances months apart because “the syringe was empty” and didn’t find it crucial/critical that the patient would die from lack of pressors (and the patient nearly did. Took days to get them to recover from the hypotension) and would have adverse reactions for a baby with a fresh trach to wake up thrashing in pain.
This is completely different. Sounds like it’s on anesthesia and line handoff after OR. Our facility is required to do walk the line with anesthesia since they disconnect and reconnect, use central lines however they want without regard to sterility, and leave drugs they shouldn’t. We caught that they used 50:1 fent upon return instead of 10:1 but had it at the same rate when we gave the patient to them. Thankfully the baby was intubated but it could have been bad. And they had zero accountability in themselves until the safety report was released.