OPIANA, CHRISTIAN JOSEPH I.

BSN 4 BLOCK 6
N036 NCM 118N
CASE STUDY CHAPTER 2

Harold Grier is a 45-year-old (200-pound) man who suffered a gunshot wound to

his chest. On arrival in ICU from the PACU, he is intubated, has a ventilator, and
a chest tube. His blood pressure is 170/00, heart rate 90, and he is grimacing
and agitated. His last pain medication was morphine sulfate 4 mg IV 1 hour ago
in the PACU. He is mouthing "Help me" to his nurse and pulling at his IV and ET
tube. His blood gases and oxygen saturation are acceptable. The physician orders
4 mg morphine IV push now followed by a morphine infusion beginning at 4
mg/hr. In addition, he orders midazolam 0.05 mg/kg and a midazolam infusion to
be started at 0.1 mg/kg/hr.

1. What is the dose of midazolam that the nurse will give IV push?

4.5mg of midazolam is given to the patient via IV push. Midazolam is a strong

sedative that must be used with caution and gradually. Titration is strongly
advised to safely achieve the desired level of sedation based on clinical need,
physical condition, age, and concomitant medication.

2. How many mg/hr will the nurse set the midazolam infusion?

About 9.1mg/hour of midozalam will be set in infusion. 3.

Are these appropriate doses? Why or why not?

The initial dose for adults under the age of 60 is 2 to 2.5mg given 5 to 10
minutes before the procedure begins. Additional 1mg doses may be administered
as needed. The average total dose has been found to range between 3.5 and
7.5mg. A total dose of more than 5mg is usually not required.

These doses are at the upper end of the therapeutic range. If the patient is also
receiving an opioid, they are usually reduced by 30% to 50%. (and Harold is). As
a result, these doses may be excessive.

The nurse notes the patient's levels of pain and agitation using the appropriate
scales and administers the IV push doses of morphine and midazolam. Then she
begins to set up the IV infusions of morphine and midazolam. The morphine is
available in the standard concentration for the hospital of 1 mg/mL and the nurse
sets the infusion at 4 mL or 4 mg/hr. The midazolam available from the
pharmacy is 50 mg/50 mL. When she adjusts the new pump, she does not notice
that the standard concentration for that pump is 50 mg/100 mL. She allows the
pump to do the calculation and sets the dose at the calculated mg/hr or
midazolam. Three hours later, at the change of shift when the oncoming nurse
evaluates the patient, she is unable to arouse him and notes he is no longer
initiating any respiratory effort. She reviews the settings on the pump and
realizes that the midazolam has been infusing at the wrong dose and rate.

4. What should the nurse do?

The nurse must:

a. Notify the doctor.

OPIANA, CHRISTIAN JOSEPH I.
BSN 4 BLOCK 6
N036 NCM 118N
b. Adjust the rate of midazolam infusion according to the appropriate
concentration and physician's advice.

c. Continue to monitor the patient and titrate the rate to the patient's
desired response level.

d. Report the incident in the proper manner and fill out the necessary
forms.

5. What factors contributed to the error?

The standard concentration used to calculate the drip rate on the pump was 0.5
mg/mL, whereas the pharmacy dose of midazolam was 1 mg/mL. As a result, the
patient received twice the normal dose of midazolam per hour.

6. How could they have been prevented?

Error reporting can lead to system-wide changes that improve patient care.
Things that could have come in handy in this situation include:

• Automatic notification by the pharmacy or pump when a high dose of a

drug is to be administered

• The hospital uses only one concentration of each medication, with the
pumps programmed for that concentration.

• Each time a medication is hung, check the concentration of medication in

the bag and on the pump.

• Checking sedative and narcotic doses with two nurses

• Thorough training on new products, particularly IV pumps

• Appropriate application of pain and sedation assessments

7. What factors compounded the error?

The problem began with a high level of pain, followed by the provision and
subsequent infusion of a dose of midazolam at the high end of the therapeutic
spectrum, and a lack of ongoing sedation assessment. The nurse's lack of
experience with a new pump exacerbated the situation.