I could only dream that it would be so, but we do document theses events at our facility.  Our forms for this are even on line now, to make it a little simpler.  Cost, as usual, is a factor in this because fosphenytoin is so very expensive compared to Dilantin.  Here we go again!
 
Heather Nichols RN BSN CRNI
Infusion Services
University of Louisville Trauma Institute
530 S. Jackson St.
Lou. Ky. 40202
(502)562-3530

>>> <[EMAIL PROTECTED]> 02/15/06 11:15 AM >>>

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


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