[17714]
Pt was admitted to hosp on 2/14/96 for an intracranial hemorrhage and had a ventriculostomy tube placed. Nurse administered kefzol at approx 6:20 am on 2/18/96, which was ordered as a prophylactic antibiotic. Instead of administering the kefzol intravenously, as ordered, the nurse injected the kefzol into the ventriculostomy tubing. At 7:00 am, the day shift began. The charge nurse for the night shift and the primary nurse for this pt advised the day shift charge nurse that she had been experiencing nausea and vomiting. At approx 7:05 am, a nurse entered the pt's room to administer the anti-emetic medication as ordered, ondancetron. At that time, it was discovered that the piggyback iv line had been connected to the ventriculostomy tubing. This was corrected and the ondancetron was administered through the peripheral line. Dr of neurosurgery, was notified of the incident immediately. The pt continued to complain of nausea and headache, but the emesis stopped. The pt displayed anxiety and was shaking. Ativan 1 mg iv was administered at 7:45 am. The pt proceeded to become more anxious and started to hallucinate. Haldol. 25 mg im was given at 8:55 am. At this time, dr entered the room and ordered the pt to be transferred to the sicu for closer observation. The pt continued with hallucinations and screaming aloud. Prior to the pt leaving for the sicu, ativan 2 mg iv was administered at 9:30. Dilantin 500 mg iv was ordered and started on the pt at 9:45 am, immediately prior to pt leaving unit 65. Just before reaching the sicu, the pt coded and was asystolic for approximately 10 minutes. Life support was begun; however, subsequent scan findings met the criteria for brain death. Life support was terminated and the pt expired 2/19/96 at approximately 8:00 pm.
Patient Sequence No: 1, Text Type: D, B5