[Jadranko]

I'am new to the forum, but to share a experience a few years ago, I'd like to hear from nurses and what they think too. A post open heart patient that was supposed to have a fairly uneventful post op course went into VT without a pulse. The nurse went to talk to the surgeon which was now returning back to the hospital and demanded the nurse stay on the phone with him while the team and other nurses where at the bedside. I t was a teaching hospital so over the phone the MD countermanded some of the orders the residents were ordering. Am initial potassium level came back at 3.8 and the MD ordered replacement this were the days it was kept in a vial not pre mixed. The charge nurse was ay the bedside since the patients nurse had to be on the phone with the MD, this nurse turned up IV fluids to 999/hr and another nurse dropped the potassium in the buterol of the IV.
No one realized the cause of the new aystole and the MD was just arriving with the OR staff, crack the chest. Labs redrawn and code continued, then the labs came back, He then realized the patient potassium level of 7.5 is why he has to pronounce her dead to the family. He came back to the room, the code team was gone, asked us to draw the curtain and heres the wild part. He had us start coding efforts, bagging, open heart massage. Dextrose, insulin, and lasix boluses, with q 15min lab work. She came back to life and a week later went to tele, no obvious neuro insult. The family praised the MD and the medical staff for the miracle. The chart only reflected the patients had a lethal vent. rhy. change. So whats your take on the case?? Would you want to know if your loved one was killed, be it by accident, you would lose your job by telling the truth??would you??

[Old_School]

I guess we now know why they don't trust us with potassium anymore.

Kudos to the surgeon . . . that was pretty gutsy. I still can't believe it actually worked.

[Ricu]

Wow! What a story with an amazing outcome. To answer the question, I think it would have been appropriate to tell the family about the potassium. This was a happy circumstance but even if it wasn't the right thing would be to tell the truth. Furthermore, I don't think terminating the nurse who gave the potassium would be the right way to handle the overdose situation either. She made a grave mistake but it was a mistake just the same. This example illustrates the reason why Kcl isn't available in vials anymore; obviously it was a problem. This is called a sentinal event and should serve as a teaching opportunity. From the study of this and other occurrances, procedures are developed for the purpose of avoiding similar mistakes in the future.

R