When Nurses Harm Their Patients

I've had to deal with this head on in a couple of situations over the last week.

Scenario 1: (By word of mouth, but from a couple different sources that were highly corroborative.) Patient goes in to deliver baby, ends up heading to the OR for a C-section. Sometime after recovery, nurse draws up a dose of insulin, has a coworker cosign the dose, and administers it to the patient. The patient? Not a diabetic, and the wrong patient completely. The "dose"? 100 units, and the wrong dose. The patient's blood sugar? 3 mg/dl. Patient in a coma, nurses both fired.

Scenario 2: My patient at work. In for acute renal failure, 6.9 pH. Most likely septic shock--pressures 80s/50s while maxed on dobutamine, vasopressin, and norepinephrine, lactic acid over 13, anion gap 47, H&H was 7.2/24, zero bowel sounds, frank blood from the OG tube. Dead gut? Patient is vented. Past medical history reads like a patho textbook--100 year pack history, COPD, diabetes, CAD (s/p CABG), PAD, hypertension, hyperlipidemia, etc, etc. The patient was sick, sick, sick. Throughout my shift we'd managed to keep her stable enough. Minimal sedation, and minimal bucking of the vent--we were able to calm the patient by talking to her and repositioning. The night shift nurse comes on and receives report. Her first question is inquiring about what we've been using for sedation, and when she hears, "Nothing," she runs off muttering about how she wasn't going to have her patient bucking the vent all night.

Minutes later she comes back and says, "The patient has an order for propofol, I'm going to hang it."

My preceptor and I both freak out, saying, "With a pressure like that?"

She replies, "It's ok, I have pressors."

"But you're maxed out on all three of them!!"

I was actually planning on staying several more hours, but it wasn't very long before that nurse did indeed hang the propofol. I left, and went home.

I stopped in to work a couple days later and inquired about the patient. The patient coded and died that night. It seems her pressures bottomed out, and they couldn't get her back.

Scenario 1 just leaves me in awe. I hear she had to use two syringes to draw that dose--wouldn't that kind of trip the double-check-o-meter right there? And the nurse that "cosigned"? Oh my. I'm so going to be the un-cool nurse that demands to see the syringe and vial both when cosigning medications. I think that most people think that that procedure is in place to catch those newbie nurses with no experience that are bound to screw up. To me, those nurses aren't the ones to worry the most about. The really dangerous situations are when the nurse is experienced, and a level of trust has developed with coworkers. "I'm busy right now, but go ahead and give it and I'll cosign it later." And then some shift, just like any other shift, an experienced nurse makes a silly mistake and someone gets hurt, and the procedure has been worked around and failed. I believe the safety policies are most importantly in place to catch mistakes of that nature.

Scenario 2 frustrates me. The patient was clearly very sick, and quite probably was going to die. But I can't help but wonder if her death wasn't hastened on by the administration of a drug that is known to drop pressures, often precipitously. But what should one do when faced with such blatant disregard for critical thinking or patient safety? Who do you report things like that to? Do you report it? What happens when you have zero trust in the staff person you're handing a patient off to, or getting a patient from? How do you protect your patient and yourself in situations like that?

Any of you with more experience care to comment?