Question

Precise measurement of doses in I mL and 3mL syringes. In the following situation an inco dose was administered because the computed volume was not rounded properly. ERROR: Rounding more decimal places than are necessary and selecting the wrong size s SCENARIO: A newbom infant was to receive gentamycin sulfate 7.5 mg. intravenously 24 hours. Using a 2 mL vial supplied with 10mg/mL of gentamycin, the nurse calculated volume needed as 0.75mL. This volume may be delivered precisely using a 1 mL syringe rounding is needed. In this case, the nurse rounded 0.75 to the whole number 1 and admin 1 mL of medication using a 3mL syringe. He infant was given 0.25 mL or 2.5mg addition medication. If the nurse continued to care for this infant on subsequent days, the error mi continue with serious overdosage implications. 1. If the nurse would have cared for this infant, continuing with the wrong dosage how additional medication would this infant have received in 7 days? 2. What are at least 3 serious outcomes had this medication error continued for 7 days 3. Why are blood levels ordered during the administration of gentamycin? 4. What would have been your action(s) had you discovered this medication error?! 5. How could this medication error been prevented? A. Compare the calibration of a 1 mL syringe with a 3 mL syringe B Is gentamycin considered a high alert drug?! Reviewed 9/18

Answer 1

Ans) 1) Daily 0.25 mg extra dose was administered by the nurse.

So calculating for 7 days: 7 × 0.25 = 1.75 mg.

2) Symptoms to gentamycin toxicity:

- Dizziness.
- Vertigo (sense of the room spinning or loss of balance)
- Hearing loss.
- Ringing in the ears.
- Numbness.
- Muscle twitching or weakness.
- Breathing difficulties.
- Decreased urination.

Serious outcomes:

- Neurotoxicity (spinning sensation [vertigo], loss of control of bodily movements)
- Gait instability.
- Ototoxicity (auditory, vestibular)
- Kidney damage (decreased CrCl)
- Kidney damage if trough greater than 2 mg/L.
- Swelling (edema)
- Rash
- Itching

3) Gentamicin and other aminoglycosides are cleared by the kidneys, and it is therefore important that renal function is assessed before treatment starts.

- It is important to ensure an accurate renal function value is used to reduce the risk of toxicity.

4) Making a mistake is bad, but not confronting it is worse. Correct your error(s) by making sure minimal or no harm is done by addressing the problem right away.

- Once the error is under control, follow the policies of your organization so the error can be understood and learned from as a means of preventing a similar occurrence from happening in the future.

- Lastly, don’t dwell on your mistake; just be sure to learn from it so that you don’t repeat it. Do everything in your power to right your wrong and then move on.