Co-signature for Insulin administration

[MissRN7]

Hi All!!

I am a new RN and hope to get job at a hospital or nursing rehab so I can build my nursing skills and confidence.

I have heard rumors that some cna/pca dont check blood surgar of pts

and just write a random number. What do you do if you suspect this? Should a nurse check the blood surgar just to be on the safe side for each pt that may need insulin?

Also I would like to know do nurses co-sign to adminster insulin? What do you do if you are alone for example a school nurse or your alone on the unit?

Thanks!

[Vespertinas]

It's just like if someone were to verbally tell me a lab result and expected me to give possibly dangerous meds because of that lab, I would want to check it first to make sure.

That's what I'm driving at. I don't know about your facility but I am required by policy to check the computer and verify a blood glucose before giving insulin. If they don't upload automatically I'd check the glucometer and verify by MRN. Even that takes less time than doing the blood sugars yourself.

Like you said, you'd double check all your values before implementing a possibly harmful intervention. That kind of mistake (wrong value or wrong pt) can happen for any number of scenarios. Wrong BP, given BP medication. Wrong blood draw, electrolytes repleted. Wrong urine output, fluid bolus given. Wrong weight, diuretic not prescribed. Wrong temperature, fever workup done on wrong patient. I don't think that means we should strip techs of their right to do those things.

My point is that there should come a point where we can trust that our techs are competent at their skills but at the same time employ the techniques of multi-level checks that we've been trained to use for the purposes of patient safety. We all can make mistakes but that's why in healthcare we try to have a lot of checkpoints where they can be corrected. Sure, it creates a longer chain of command but that drawback is totally worth it for the benefits of teamwork which ultimately save you time to do OTHER RN interventions instead of getting fingersticks on all your patients.

[SionainnRN]

All good points. I've just never worked anywhere that techs are allowed to do finger sticks, so for me it would be really weird!

[Orange Tree]

CNAs are more than capable of handling accuchecks if properly trained. Some things I've learned are:

1. Let the CNA know which blood sugar results you need reported to you immediately. Don't assume they will come get you when a 40 pops up unless you've asked them too.

2. If a result is not charted yet (in the computer), look at the CNA's paper charting and ask them to confirm the result. I ask like this... "Mrs. Smith's blood sugar is 210? ...the petite lady in room 404, by the window, wearing the blue bunny slippers?"

3. Compare the result to the patient's other blood sugars. Before I give 14 units of humalog to cover a 490 blood sugar, I'm going to see what the patient's been running. If they've been between 70 and 90 all day, I need some sort of really good explanation to proceed.

4. If a miscommunication does occur, approach it as a miscommunication without becoming "angry". Make sure the patient is safe and the appropriate people are notified, then work on a plan to communicate better and keep it from happening in the future.

I've never heard of CNAs making up blood sugars. Yikes!

My facility requires a co-sign for all insulin administrations, but it's rarely done.

[buytheshoes11, MSN, RN]

Our facility does not allow anyone but the licensed nurse to perform BG checks. In order for us to give Insulin we have to have another nurse double check the order and the amount to be given before our eMAR documents that the proper dose was given. This can be a pain at times but I don't think it's a bad thing to do this.

[wooh, BSN, RN]

Techs aren't competent to check blood sugars. Nurses aren't competent to draw up insulin by themselves.

It's a wonder anyone survives their stay in the hospital as stupid as we assume the people working there must be.

[BrandonLPN, LPN]

I think it's just inefficient to have the aide check the blood sugars and the nurse to come in 10-20 min later to give the coverage. Why not just have someone (the nurse) do it all at once. Especially on night shift, it would save the pt from being woken up every hour.

And as someone who has worked in a hospital and in LTC, I firmly believe that one of acute care's biggest failings is the lack of attention to ADLs. Pts in hospitals rarely get fed or up out of bed as much as they should. This is because the aides are too busy checking vitals, accuchecks and I's and O's. Hospitals *need* a classification of people who's sole job function is direct care. Adding all these extra duties to the "tech's" workload only seves to ensure basic care falls to the wayside.

[PediLove2147, BSN, RN]

I did my practicum at a hospital that required insulin to be double checked, I now work at a hospital that doesn't. I am so happy for that! I am capable of checking my own insulin and ensuring it is correct. And like others have said, blood sugars are automatically uploaded to our computers so I know I am getting the right number. I also trust my CNAs..

[RNinCLE, ADN, BSN]

As others have said, our glucometers transmit the BG into the patient's chart, so there is no question it was actually done. We dual-sign insulin, but I work on a pediatric floor. The adult floors do not require dual-signing.

I don't know - I don't mind having my insulin double-checked. It's not a big deal to me. I'd rather have someone confirm it's right than overdose a child.

As for being the only nurse on the unit, that would never happen where I work. We are required at all times to have two RNs on the floor.

[CrazyGoonRN]

Unless its up loaded directly to the computer I'd do a recheck to feel comfortable giving the insulin. Where I work (not a hospital) nurses check BS's, draw up and give all insulin. I was recently doing clinicals (for RN school) at a local hospital and my pts scheduled dose of lantus was sent up from the pharmacy already drawn up in a syringe ready to give. I felt really uncomfortable giving the lantus that someone else drew up. What if they made a mistake and filled it with Levimir or regular insulin?? That was all I could think about. I felt better when my pt refused to let me give the shot since I'm a student so my instructor gave the shot. Unbeknownst to the pt I'm an LPN and I can give a darn good shot, lol.

[chrisrn24]

Unless its up loaded directly to the computer I'd do a recheck to feel comfortable giving the insulin. Where I work (not a hospital) nurses check BS's draw up and give all insulin. I was recently doing clinicals (for RN school) at a local hospital and my pts scheduled dose of lantus was sent up from the pharmacy already drawn up in a syringe ready to give. I felt really uncomfortable giving the lantus that someone else drew up. What if they made a mistake and filled it with Levimir or regular insulin?? That was all I could think about. I felt better when my pt refused to let me give the shot since I'm a student so my instructor gave the shot. Unbeknownst to the pt I'm an LPN and I can give a darn good shot, lol.[/quote']

To play devils advocate here, how do you know that the insulin in the physical bottle you normally draw it up from is what it is? It could've gotten switched at the factory, etc.

At some point you just have to either trust it or

Advocate for change.

[Nurse_]

Frankly, I don't feel comfortable having the tech check blood sugars. It's not because they don't know how to (it's really a no brainer) but the amount of time before they can deliver the result to me.

If the tech/CNA takes the BG for everyone in his/her round, by the time the result gets to me, it's already 30 to an hour after. Meaning, the results aren't accurate anymore.

When I'm on the floor, I usually take BG right when the food trays come. I know that the dietary staff takes about 20 minutes to pass the first set of trays for diabetics, giving me enough time to take the BG, find a co-signer, and give the insulin. It's more accurate and it takes about 5 minutes of my time to finish the whole process.

[blackvans1234]

What kind of mistakes can you make with an accucheck?

Wipe finger with alcohol, wipe dry with cotton, poke patient, wipe away first drop of blood, take second drop of blood.

If you don't let the alcohol dry I've heard it may cause an error in the reading. I would assume the same CNA / PCT that doesn't wipe the alcohol dry is not wiping the first drop of blood away.

------------------------

As a CNA, we take blood glucoses, I used to tell the RN's what it was, one of them asked to see the machine, and that's fine by me. Now I just give them the machine when i'm done checking the sugars.

One less thing to get mixed up.