med error

  1. 0 Made my first med error today and Im 2weeks away from clinicals being over. So my patient gets Lantus BID...20 units and her blood sugar for before breakfast was 100...I gsve the Lantus and did not see the hold parameters for BG less than 110. My CI did not catch it either. Thankfully it was fine..just had to make sure she ate her breakfast and fill out an incident report. I am just bummed I didnt catch it. Uggg
  2. Visit  MendedHeart profile page

    About MendedHeart

    Joined Mar '13; Posts: 536; Likes: 241.

    11 Comments so far...

  3. Visit  kylee_adns profile page
    0
    Med errors happen. Learn from this and make sure to really pay close attention in the future. Usually the parameters are included in the eMAR, so you can include it in your med checks. I am very surprised that your teacher or the RN taking care of the patient did not catch this. In my hospital RNs are required to double check insulin with another RN. We do this to help minimize errors, but still they can happen. I am glad that your patient was ok! Good Luck!
  4. Visit  MendedHeart profile page
    0
    Thank you. .im about to graduate and am really mad that I didnt catch this. Thanfully my instructor acknowledged that it was partially her fault for not catching it either but I am a perfectionist so I am not happy that I was so focused on pasding my meds in a timely manner rather than being thorough in checking the meds
  5. Visit  turnforthenurseRN profile page
    0
    Quote from 2013SNGrad
    Thank you. .im about to graduate and am really mad that I didnt catch this. Thanfully my instructor acknowledged that it was partially her fault for not catching it either but I am a perfectionist so I am not happy that I was so focused on pasding my meds in a timely manner rather than being thorough in checking the meds
    We are all human and we are all bound to make mistakes. It happens. You live and you learn! I'm glad everything ended up being okay in the end.
  6. Visit  psu_213 profile page
    2
    Quote from 2013SNGrad
    Made my first med error today and Im 2weeks away from clinicals being over. So my patient gets Lantus BID...20 units and her blood sugar for before breakfast was 100...I gsve the Lantus and did not see the hold parameters for BG less than 110. My CI did not catch it either. Thankfully it was fine..just had to make sure she ate her breakfast and fill out an incident report. I am just bummed I didnt catch it. Uggg
    I wouldn't beat yourself up too much...especially considering there often isn't (and really should not be) parameters for Lantus.
    Hygiene Queen and fairyluv like this.
  7. Visit  Esme12 profile page
    0
    Quote from 2013SNGrad
    Thank you. .im about to graduate and am really mad that I didnt catch this. Thanfully my instructor acknowledged that it was partially her fault for not catching it either but I am a perfectionist so I am not happy that I was so focused on pasding my meds in a timely manner rather than being thorough in checking the meds
    ((HUGS)) we have all made mistakes...it happens sometimes. Nursing is a tough job. Now, Forgive yourself and learn from it.....((HUGS)). You are very smart! Although I would feel the same way.....Allow yourself to be human.
  8. Visit  MendedHeart profile page
    0
    Thanks everyone. .yall really made me feel better!!
  9. Visit  hodgieRN profile page
    3
    Hmm.. I've never heard of holding lantus by using the morning glucose level. I do that for the short acting ac/hs sliding scale. Lantus should always be given and if the blood sugar is low at some point during the day, you just treat the hypoglycemia and continue. Lantus doesn't really have a peak and it last for 24 hrs. I would think the glucuse level was 100 (and not 200) because the pt was on lantus. Only time you hold it is if the pt was NPO. If it was held, who's to say that the pt's glucose level would be 300 by dinner time. Interesting...
    KelRN215, Hygiene Queen, and psu_213 like this.
  10. Visit  psu_213 profile page
    0
    Quote from hodgieRN
    Only time you hold it is if the pt was NPO.
    And even if they are NPO, there are times when it is not held...per doctor's orders of course.
  11. Visit  RLtinker profile page
    0
    Med errors are not good. But it is strange that there is a hold order on a long acting insulin like lantus.
  12. Visit  KelRN215 profile page
    0
    Quote from hodgieRN
    Hmm.. I've never heard of holding lantus by using the morning glucose level. I do that for the short acting ac/hs sliding scale. Lantus should always be given and if the blood sugar is low at some point during the day, you just treat the hypoglycemia and continue. Lantus doesn't really have a peak and it last for 24 hrs. I would think the glucuse level was 100 (and not 200) because the pt was on lantus. Only time you hold it is if the pt was NPO. If it was held, who's to say that the pt's glucose level would be 300 by dinner time. Interesting...
    That was my thought when I read the OP too... why would you hold lantus for a level of 100?
  13. Visit  dandk1997RN profile page
    0
    Agreed that I don't understand holding a long-acting insulin under those circumstances. We only hold if our pt will be NPO for surgery or has been hypoglycemic....


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