My first med error (Rant)

[MissHaleyDawn]

I need a little support. I'm a fairly new nurse, just under a year and I made my first error on my shift last night.

At my hospital, the nurses aide will collect vital signs and blood glucose values. The glucose meters are supposed to dock and download the results to our computers in just a few minutes. But it's common that these meters take hours to transfer results...one night I had results pop up from two shifts prior! So the nurses often times rely on the BS value the aide has written down.

This is what I did, as my aide had docked her meter and the results were taking a while to download. She had written down a value of 277 and per the patients scale I covered him with 8 units. About an hour and a half later the BS results post to my computer...the value didn't look right so I pulled up my administration record and my heart sunk. I'd basically double dosed my patient - his BS had been 177 and the scale called for 4 units.

The patient was and had been asymptomatic for hypoglycemia since the med administration. I called the MD anyway; he didn't seem too concerned and was very nice about it. Just told me to watch the patient and give him an Ensure for good measure. Around the peak time of the insulin I rechecked the value and it was 188.

I filed an incident report as soon as I realized I made an error. I'm just so worried I'll be seriously reprimanded for the error. I admit and own up to my error...but at the same time I can't help but feel that our computer system is the true weak link in the system for preventing this type of med error. Up until the system updated, I had done my job correctly with the information I had. I did what I was supposed to do to monitor the patient for adverse effects and filed a report. Just hoping the administration sees the honesty and integrity of my incident filing. ): It's made worse because I'm a perfectionist; it's a kick to my pride that all my checking and rechecking didn't and couldn't do squat simply because I had the wrong numbers.

[KelRN215, BSN, RN]

Not to veer too much off topic, but I've never understood why hospital floors have the aides check the blood sugars. In LTC it's a licensed-nurse-only duty. The nurse giving the insulin is the nurse who checked the BS. How much time does it really save to have the aide check them? Why not just have the nurse check the BS and give the coverage all in one trip?

When I worked in the hospital as a nurse, it was nurse-only too. This was a pediatric hospital and I didn't work in endocrine so we rarely had diabetics. We often had kids who needed sugars for other reasons though... ketogenic diet initiations to make sure they didn't bottom out, high dose steroids if their urine was positive for glucose. I barely trusted our aides to do vital signs when I worked in the hospital (too many times there would be a "perfect" BP documented and no such value on the monitor) so even if they were allowed to, I doubt I'd have wanted them to do sugars for me. Most of the time when we had diabetic kids, the parents arrived with all their own equipment which they were allowed to use as long as we checked the value against our machine for accuracy the first time. We could accept the values they checked only if they showed it to us on the screen.

When I worked in the hospital as an aide (different hospital), we did all the blood sugars.

[knittygrittyRN, MSN, RN]

It seems some places are going back to nurses doing vitals and blood sugars; at least in my area. I'm at a fairly large hospital and we have multiple trial floors where we have nurses doing all fingersticks for patients and performing at least the first set of vitals on their shift. Since we gone this route our hypoglycemic events have decreased dramatically and are addressed right away. From the sound of it, it appears eventually the whole hospital will convert in due time much to the dismay of some staff.

[RNnetwork]

I so can relate to feeling like this as a new nurse. I feel pretty seasoned now, but I can relate so much!!! You did an excellent job bc you assessed your patient, reported your error, and filed a incident report. I've worked on a lot of committees and when you do, you learn to a lot. Incident reporting isn't meant for you to be reprimanded, its to track trends. The problem isn't what you did necessarily, but there is definitely an issue with the process in place on your unit. Don't beat yourself up, take it as a chance to take the initiative to do an process improvement project. I'm sure you are not the first to do this. And doing projects like this is something to really boast about on job interviews. Learn more at nursanity.com

[applewhitern, BSN, RN]

At my present hospital, only the licensed nurse can do blood sugars, period. They claimed too many mistakes happen.

[LongislandRN23]

Every favility has different protocols. I wouldn't blame the computer system this error, although I think its absolutley absurd for fsbs results to take an hour and a half to upload. I mean this is 2013 right? I do all my own fsbs. Just as if a pca/cna told you pts BP was 190/76 with the VS machine wouldn't you double check it manually? Final thought I would not go by written results thay were delagated. I would have checked it myself and def not waited an hour and a half for it to upload.

[jadelpn, LPN, EMT-B]

This is definetely a process issue, and should be addressed as one. However, when I rely on a BS to give or not give a medication, I find it easier to do myself, along with the first set of vitals. I think that way, I have a full assessment at the start of the shift.

With others taking a bunch of sugars, then they are bound to forget which sugar belonged to whom.

This information should be readily available, especially if you are responsible for medicating or not medicating same.

But you can only go from here. It would be something that from now on, I would do as part of my assessment. And DM patients first.

[hofamb]

I just graduated NS, but have worked as a tech/aide on 2 different units within a very large research hospital for the last 2 years and have always taken the BS for every patient assigned to me. That's just how our units are set up, but we don't rely on writing the correct number, we put them in the computer (by hand) in the pts room and then verbally tell the nurse. I've never heard of any issues on either of my units.

[kathconserv]

This :)

That is not a big deal. Believe me. You will be ok.

[nurseladybug12]

The almost exact same thing happened to me. My aide reported a BS to me, but it was for A bed, not B Bed and I gave B Bed too much insulin. I rechecked his BS after and it was 89, he was asymptomatic and we gave him some juice and crackers to hold him over until his tray came around. I was upset at the aide, but ultimately it was my fault because I did not realize we had a policy saying either we have to see the accucheck result on the emar or we have to see it on the screen of the meter at the bedside. After that, I did file a PSR, and I was never reprimanded by my manager, but I know that if I were to do this again I wont get such a great review at the end of my 6 mo probation period. I learned it is just unsafe to take the word of anyone, and if you have to take their bg again, better safe than sorry. Ultimately, you are responsible for delegating, supervising, and following up on what your aides do for you and making sure things get done right.