My first med error (Rant)

  1. 1 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.
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  3. Visit  MissHaleyDawn} profile page

    About MissHaleyDawn

    From 'North Carolina'; Joined Jun '10; Posts: 82; Likes: 28.

    20 Comments so far...

  4. Visit  ScottE,RN} profile page
    3
    When it's important I don't trust something somebody else tells me. I'd only trust Accucheck results from someone else if I was either physically present when the Accucheck was performed and saw the screen, or the results were in the computer. Too much can go wrong otherwise. Numbers get written down wrong patient results get crossed up ect. You just learn from your mistakes.
    sweetf, KelRN215, and Susie2310 like this.
  5. Visit  sugarsweet21612} profile page
    2
    I used to have the same problem at my job, so I would physically go to the Accucheck machine and look up the result with the MRN if it had not uploaded by the time I needed to admin insulin. Sad but I would not rely on them to report the result to me. Hope everything works out.
    Esme12 and nrsang97 like this.
  6. Visit  RNKPCE} profile page
    1
    Where I work if you know what machine was used you can get results from the machine based on patient medical record number . Also we had issues with aides writing down the wrong results when we had more than one patient in a room or mixing them up, they haven't been allowed to do blood sugars for over 10 years.
    Esme12 likes this.
  7. Visit  Creamsoda} profile page
    6
    This is also a sign of system issues. First, its nice to be able to trust your co-workers but you cant always. The machines should be docking instantly. Its a huge waste of time for you to have to find the glucometer, turn it on, search for the patients MRN every time you want to reverify a glucose. If theres multiple machines, that a huge waste of time trying to find the glucose. In my opinion, the aide should be talked to to ensure clear communication and held responsible. Yes I agree that its our job to trust no one, but whats the point of them getting the glucoses. might as well just do it yourself then if you have to go through all that trouble to verify it. You shouldnt be held totally responsible for this, but make it clear to your manager that they way things are currently set up are what led to this situation
    Sadala, merlee, Stcroix, and 3 others like this.
  8. Visit  HouTx} profile page
    2
    Totally agree with Creamsoda. This should be a golden opportunity to initiate a meaningful process improvement & foster a genuine Culture of Safety. Does your organization have a Nurse Informaticist available to take this on? Can you initiate it via a Quality Improvement suggestion?
    DawnJ and merlee like this.
  9. Visit  bratmobile} profile page
    1
    That's a rather suckish system going on.
    DawnJ likes this.
  10. Visit  prnqday} profile page
    1
    Seems like this is a system failure. I would request to meet with risk management and your NM to get this issue resolved. On another note: I admire you for everything you did after you found out your mistake. So many other nurses would have just brushed it off. Keep up the good work!
    DawnJ likes this.
  11. Visit  BrandonLPN} profile page
    3
    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?
    caliotter3, KelRN215, and Michaela, RN like this.
  12. Visit  Tait} profile page
    0
    Quote from HouTx
    Totally agree with Creamsoda. This should be a golden opportunity to initiate a meaningful process improvement & foster a genuine Culture of Safety. Does your organization have a Nurse Informaticist available to take this on? Can you initiate it via a Quality Improvement suggestion?
    This
  13. Visit  drowningdaily} profile page
    0
    Quote from BrandonLPN
    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?
    In my LTC job we have CNA's that check blood sugars. In my hospital job we can't give coverage while sugars are checked because you need to know how much insulin to remove from pyxis. IMO not having to do sugars saves me a ton of time in each setting. But, it can take hours to see results in computer. I look on meter if the value seems to deviate from where the patient's sugars have been.
  14. Visit  jherford} profile page
    0
    Blah on med errors
  15. Visit  KelRN215} profile page
    0
    Quote from BrandonLPN
    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.


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