Having another nurse check insulin doses & other med Qs

  1. 1
    There is talk going around work that management is thinking about requiring nurses to have another nurse double-check insulin doses, meaning another nurse would have to watch one draw it up, and sign that it's the correct insulin and dose. I'm assuming this is another check to prevent med errors.

    I've heard about this happening at some hospitals, but this is LTC, where we have up to 30 residents. Plus, some nurses have had up to 9 fingersticks to do. If this becomes an actual rule, med passes are going to take even longer. I can't imagine trying to track down a nurse for 9 fingersticks. Do you have this rule at your job?

    If this rule is done for safety reasons, then why not have a second nurse around for other "risky" drugs, such as narcotic pain meds and coumadin?

    Another question: some residents have orders for narcotic gels, such as Ativan, that are to be applied to different hairless areas of the body. I'm curious: should the nurse clean the particular area of the body before applying the gel, such as the inner wrist? The instructions don't mention anything about washing the area before applicaton.

    In addition, would the drug would lose potency if it was applied to the left inner wrist twice a day without washing that area between applications? I wanted to apply it on the upper back, just to rotate sites, and a nurse said it should only be on the wrists. I thought that as long as the area doesn't have hair, it's okay to apply the gel there. Am I wrong? Thanks.
    CaLLaCoDe likes this.
  2. 55 Comments so far...

  3. 11
    I started in pharmacy 15 years before nursing. One day a week, I still work at it doing compounding. I make similar gels. They are typically in a pleuronic lecithin organogel. The phospholipids help the drug pass through the skin. The site does not need to be cleaned before administration unless the skin is soiled. The site should not be cleaned after application for 30 min to an hour (an hour is better). Failing to rotate sites may decrease absorption but little is known about the extent of variation in absorption due to the dearth of studies done on compounded products. It is helpful for it be applied to skin that has good circulation. If you want faster delivery, apply over a well vascularized area where blood vessels can be seen. If you want slower absorption with greater sustained action, the thigh may be better.
  4. 1
    I think that the check insulin rule that your Hospital has adopted might be augmented to require a dual signature if and when the insulin dosage exceeds 6 units. Perhaps that would cut down on the time waisted going to and from coworkers to do double checks and cosigns. I must admit, having come from California, which has this rule (2 nurses sign off) to Oregon which does not, I would find myself checking with another RN anyway, especially if it was a concern regarding the amount I was giving. I felt safer doing it this way. Similar to applying the 5 check rule when giving meds to anybody. Safety is the best policy!
    Plagueis likes this.
  5. 2
    We have to double check our insulin in our hospital. Even for 1 unit. There are other meds that require this also, but not ones that are used frequently on my floor. PCA requires 2 nurses to sign off on just about anything except clearing and checking the pump. Any adjustments require 2 people.
    Plagueis and CaLLaCoDe like this.
  6. 11
    I know, don't use logic against me I can titrate massive hemodynamic drugs, insulin drips, push adenosine and run a code without a second wittness, but dare I give one unit of insulin??? We double check heparin as well, even sub Q, not lovenox though... argh I could go on and on.

    While I obviously understand the safety reasons, and sure as snot someone here will lecture them, if I'm not competent to give sub Q heparin, then don't trust me with a wall of drips running 10 plus IV's and repositioning a swan while managing a balloon pump.

    So yes, double check insulin

    dancing off the soap box
    Last edit by Zookeeper3 on Jan 3, '10 : Reason: sppellin
    RNKel, OldnurseRN, blueheaven, and 8 others like this.
  7. 2
    We've been required to double check all "high risk" drugs for as long as I've been at this hospital,.(14yrs),..this includes insulin, heparin, lovenox...
    Plagueis and CaLLaCoDe like this.
  8. 2
    I know that I've worked in longterm care facilities where having two nurses check insulin doses would have been downright impossible. Witholding insulin for the amount of time it would have taken to even track down a second nurse was most likely more risky than just giving the insulin without the second check. And holding all of those meals ??? Blah!

    My rule is that I feel confident enough to draw and give insulin myself. I do have a second nurse check when I'm taking care of an unfamiliar patient with extreme insulin orders... for example a lady where I currently work who gets like 30 units of Novolin R and I think I've had a guy with 75 units of Lantus! I believe he had an insulin absorbtion issue. No way was I giving that much insulin without double and even triple checking.
    Plagueis and CaLLaCoDe like this.
  9. 4
    Back in the day -"Old School" we were taught to always have a second nurse double check your insulin dosage and correct draw prior to administration. We were also to do this with Heparin doseage for injection. I still keep in the habit of doing same as I have for 30 years. Primarily as my sight isnt so good anymore and those little lines on insulin and tb syringes all start to blur together LOL. I'd rather ask someone to double check my draw to insure I'm not making an error that I cant take back. It only takes a second to ask some one "Double check this do I have 10u drawn accurately".
    tkane, Teacher First, Plagueis, and 1 other like this.
  10. 2
    we always have another nurse check it, no big deal. It should be checked anyway! There's always someone in the med room or close by and they look and sign their initials on the diabetic flow sheet. We just hold it up and announce "___ units of ___ for a blood sugar of ____," and someone takes 2 seconds and signs the sheet. On my unit we have 6 patients and very often all 6 have insulin orders, so its definitely doable and not a big deal.

    And I would clean the area with an alcohol wipe after removing a patch, but if the skin looks dry and clean I probably wouldn't clean it before, but I try to give all my patches after bath time. Anyway, it wouldn't take very long to whip out an alcohol pad and wipe, so do what you feel comfortable with!
    Plagueis and CaLLaCoDe like this.
  11. 8
    What I'm about to say is sad. At my hospital we are required to sign off on each other's insulins; yet that is really all we do. Unless someone is getting something crazy like '30 units of Novolog R' or '75 units Lantus' we very rarely actually look at the dose that the other nurse is giving. I find this sort of frustrating as I know why the rule exists; yet I can't help but feel as others have stated about the fact that I'm allowed to administer crazy meds like levophed, dobutamine, dopamine, etc. without someone checking it but I have to get someone to sign off on 2 units of insulin? Really?! And, no, it would not be easy on my floor to find someone to actually look at what I was drawing up as I drew it up and have the watch me administer it to the proper patient. Which, to me, should be the proper way to "sign off" on a medication. Kind of like what you do when you administer blood. Thus I think the rule is stupid.
    Just a Dose, Zookeeper3, canoehead, and 5 others like this.


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