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.
    prnqday likes this.
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  3. 20 Comments so far...

  4. 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. 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. 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. 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. 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. 1
    That's a rather suckish system going on.
    DawnJ likes this.
  10. 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. 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. 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


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