Why You Should Double Check Your IV Bag’s Info

Last week, something I’ve only read about online occurred. My 6-year-old nephew’s biologic infusion was given to someone else and he almost received their infusion. This means that an adult received his child-sized dose of the wrong medication. And a child, my nephew, ALMOST received an adult-sized dose of the wrong medication.

As you can imagine, tensions ran high after the discovery was made. This is why it is of the utmost importance to double check your IV labels before an infusion starts, as well as double checking medications given to you in the hospital before taking them.

When medication errors occur

This happened to be a one-poke day, to get the IV started. Some IV starts for him haven’t been the smoothest. It was great news to hear the IV was set on the first attempt. The bad news was that it was placed at an awkward angle. Because of this, the nurse had to push his IV Benadryl by hand rather than hanging a bag. This action may have saved him from receiving the adult-sized dose of the wrong biologic.

A few minutes later the bag of the biologic was getting prepped to hang on his pole. It was then that a nurse returned to let his mother know that his medication was given to the wrong person. The nurse played it cool and acted like it wasn’t a big deal, and explained his medicine was reordered. At first, when his mom texted me the news, I truly thought oh no big deal, someone who was to get the same medication and dose got his IV bag.

These things happen. They shouldn’t, but they do.

Recieving the wrong dose of medication

A few minutes later, I got another text about them hearing a young woman screaming in panic. She had received almost the entire bag of my nephew’s biologic. She panicked for his safety thinking he was infused with her medication — an adult dose of a different biologic. Later when the chaos had settled, my nephew’s mother texted back that the young woman had once been on my nephew’s biologic and didn’t have a known allergy to it. She had just developed a tolerance to it and was moved to a new biologic therapy. However, since she had been off the previous med for some time they had to monitor her in the hospital to ensure she didn’t have an allergic reaction.

It’s my understanding that if you go off of biologic therapy for some time and return to it, you will get monitored more closely and possibly get administered a pre-medication plan to go with it.

Learning from the medication error

As the chaos dialed back down, the impression his mother received was that he very well could have received the wrong medication. My nephew was extremely lucky, but that young woman could have had it worse if she had developed a complication to her former biologic.

I commend this young woman’s drive to make sure someone else was safe. I have an allergy to the medication she received improperly, and wouldn’t have been able to even attempt to advocate for myself let alone make sure no one else was on the receiving end.

We learned this mix-up occurred because my nephew and the young woman share the same name. They spell it the same way, too. The only thing both bags had in common was the patient’s first name. The differences on the medication labels were the following: last names, birth date, dose, and type of medication. However, both IV med bags looked similar and that probably contributed to the mix-up.

Safety first

To our knowledge, the young woman was okay and held for observation to be on the safe side. This was a teachable moment for everyone and was a good reminder of proper protocols when in a clinical environment such as verifying the patient’s name and DOB with the patient or their caregiver. And taking that one step further, verifying the name of the medication before it is administered.

When you get your infusion, does your nurse verify the bag’s information with your name and birthday before attaching your line?