This is all very important information. I hope when we as IV nurses find these issues, they are being reported to ISMP. They have a link on their website to confidentially report issues exactly like this. Since they are a international organization, and independent, maybe with a collection of reports they can get some changes made--like lableing Dilantin to be given via Central line only....
Here is the link to the reporting page of their site: https://www.ismp.org/orderForms/reporterrortoISMP.asp
Chris Cavanaugh, CRNI
----- Original Message -----
From: Darilyn Cole <[EMAIL PROTECTED]>
Date: Wednesday, February 15, 2006 10:57 am
Subject: Re: [vascular] RE: Dilantin
To: Heather Nichols <[EMAIL PROTECTED]>, [EMAIL PROTECTED], [EMAIL PROTECTED]
Cc: [EMAIL PROTECTED], [EMAIL PROTECTED]
> I found a similar scenario Heather. I scanned a young adult male
> patient for a picc and found his left basilic completely
> thrombosed to the axilla. Upon review of his chart the ER had
> bolused him in the left AC with Dilantin. Subsequent doses were
> given there as well. I think the site had been in 3 days. I
> wrote up a sentinel event but nothing came of it. I wonder what
> sort of se!
ttlement
