It is my first day in NICU. Unexpectedly, I'm emotionally held up by a mistake I did days ago.
It started when a staff nurse handed me prescription slip and requested for a drug topping up for a 945 gramer preterm baby. Copying word to word from the blurring off old carboned prescription slip, it was written:
IV Vancomycin 95mg TDS
(Weight: 945g)
The drug was served for 3 courses before I was called up for an incident report. Yes I missed a dot. A decimal place to differentiate 9.5mg from 95mg. I had served 10 times more of a potential dangerous drug to a fragile preterm baby.
Now, the baby is well known as the "Vancomycin-overdosed-baby" lying in the incubator. I am well known too because of a mistake I had made. I was reminded repeatedly to watch out prescription there after, to double check dose with MO and etc. Everyone basically knows about it.
Sigh. Sad that people remember me for my mistake. Blame it on me. I did not recalculate dosage for the weight before I prescribed. I was trying to kill instead of to heal. It is worth scolding and reporting.
Thankfully the baby's renal function is not impaired. Other side effects such as ototoxicity is yet to be found out.
IV Vancomycin 10mg/kg TDS for neonates. I will remember it for life!
It started when a staff nurse handed me prescription slip and requested for a drug topping up for a 945 gramer preterm baby. Copying word to word from the blurring off old carboned prescription slip, it was written:
IV Vancomycin 95mg TDS
(Weight: 945g)
The drug was served for 3 courses before I was called up for an incident report. Yes I missed a dot. A decimal place to differentiate 9.5mg from 95mg. I had served 10 times more of a potential dangerous drug to a fragile preterm baby.
Now, the baby is well known as the "Vancomycin-overdosed-baby" lying in the incubator. I am well known too because of a mistake I had made. I was reminded repeatedly to watch out prescription there after, to double check dose with MO and etc. Everyone basically knows about it.
Sigh. Sad that people remember me for my mistake. Blame it on me. I did not recalculate dosage for the weight before I prescribed. I was trying to kill instead of to heal. It is worth scolding and reporting.
Thankfully the baby's renal function is not impaired. Other side effects such as ototoxicity is yet to be found out.
IV Vancomycin 10mg/kg TDS for neonates. I will remember it for life!
2 comments:
Jia you gal !!!
hey ching mun, it's alright to be real upset about it.
i have got a similar problem here,i was handed a prescription sheet and without double checking the dose, i simply believe in what the experienced staff nurse had to tell me..
sothe next morning i got a warning message from my boss..
so i learnt my mistake, and i insisted checking the dose from the yellow little book for..
i think we make it a worthwhile mistake by remembering it and not to repeat it in the future..
ching mun miss you here. take care=)
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