autopilot mindset med errors

[MelissaMooRN]

You know when your driving home from work, the same route everyday, and you blink your eyes and your halfway home. You don't need to think, your body just goes.

Its that autopilot mindset & muscle memory that helped me make the biggest medication error today. I wanted to hide in a corner and cry. I wanted to not be a nurse anymore.

I am a new grad, with my first job in a long term facility. I like it and most of all, I love my coworkers. I work overnight, with the same patients everyday.

I give heparin everyday I work, but I don't always give insulin. We use the same syringes for both. So of course, half way through med pass on autopilot, I pull up 1ml (100units)of insulin instead of 4units!!! My mind said heparin. My hands pulled it up as heparin. I gave it as I would heparin!!!

I was devestated. 100units of Humulin R insulin! I noticed not even 10mins later (thank god). The problem was resolved, as my pt went to the ER for observation. I still have yet to here from the DON. I'm scared and embarrassed for my job, license, my pt's life.

But how scary to think I could easily put a pt in a life threatening situation. I will, this day foward, be more aware of what I'm doing, double checking, no talking and prepping meds, and most of all no autopilot.

My heart never sunk so much in my life. I actually had my Fitbit on and my heart rate reached 116.

[Spidey's mom, ADN, BSN, RN]

Part of that is a system's error.

Prefilled heparin syringes is the answer where I work. And they addressed this years ago by making the packaging not look so similar.

Plus, always check your insulin with another nurse. I realize you thought you were drawing up heparin, but still, though I'd mention that.

Overdoses Caused by Confusion Between Insulin and Tuberculin Syringes

https://allnurses.com/nursing-student-assistance/understanding-insulin-and-973134.html

[NickiLaughs, ADN, BSN, RN]

When I worked in LTC I was the only nurse and there was no double check because I was the only nurse in night shift. Auto pilot is scary and it does happen. One time the pharmacy clerk put a neuromuscular blockade in the Pyxis where I was pulling out for a Levo drip. Did a double check with another nurse and then I looked at those bottles one last time. They were the same size, the same style writing, but then I realized....I almost passed out right there because it would have killed my non intubated patient.

I still thank god every day I looked one more time. I still check every med I pull every time out of the Pyxis.

The nice thing is this was a Learning experience and you will be exceedingly careful after this. Changes are, other than some orange juice your patient will recover. You might get written up, but the experience will benefit your practice in the long term, because auto pilot will scare you.

[Butterflyxx0621]

I'm not sure how your facility is but when I worked in LTC we scanned meds and I don't recall having to give heparin. In the hospital we scan meds, and we use different syringes for insulin and heparin. It's very odd to me that they would use insulin needles for both, that seems like setting someone up for a mistake.

[MelissaMooRN]

We don't scan meds, ours come in strips where you can rip all the 6am ones off, then 9am and so on. I feel as if my facility only has insulin or tb needles. I have two residents on heparin, however this is my fist job. Nothing to compare it too.

prefilled heparin syringes, would have saved me from this error. Also requiring a cosign for insulin probably would have helped me too (even tho it would be a pain to search for another nurse) Insulin could very easily be fatal.

unfortunatly whoever created this system, wasn't a nurse.

[Guest219794]

The Institute for Safe Medication Practices (ISMP) has received multiple reports of similar events of mixups between heparin and insulin elsewhere. Some examples follow.

• Insulin was accidentally added to infant TPN in two other states, each with fatal outcomes.
  
• A 1991 article by Michael Cohen, currently President of the ISMP, described cases of severe hypoglycemia after a pharmacist added 200 units of insulin instead of heparin to TPN and another pharmacist added 1,000 units of insulin instead of heparin to TPN.2
  
• Two nondiabetic patients died after receiving insulin instead of heparin during a vascular catheter flush procedure.
  
• Another nondiabetic patient received 50 units of insulin (0.5 mL) subcutaneously instead of heparin 5,000 units (0.5 mL).
  
• A nurse flushed a patient's central line catheter with insulin instead of heparin.
  
• Another nurse erroneously transcribed a verbal order to resume an insulin drip as resume heparin drip.”
  
• A pharmacist entered an order for 500 units of heparin into the computer as regular insulin 500 units.
  
• A nurse transcribed a telephone order for 10 units of regular insulin by intravenous (IV) push for a blood sugar of 324 as 10 units of heparin IV push.
  

[Pangea Reunited, ASN, RN]

I've done something similar while on autopilot ...probably at about my one year mark, too. I gave 50mls IV push of sodium bicarb instead of d50. They were side by side in the pixis and looked identical once out of the packaging (which I quickly ripped open and discarded on my way to the patient's room). In my case, I bypassed scanning the medication. I had given the low-risk d50 many times before. I was over-confident and in a hurry because the patient's blood sugar was critically low.

I was terrified when I realized what I'd done, but surprisingly, no one else seemed to be too bothered. As embarrassing is it is to talk about, it's a story I love to tell new grads in the hope that they won't do something similar to what I did.

I wish you the best and you are not alone although you probably feel very alone at the moment.

[TheCommuter, BSN, RN]

Hopefully the DON at your place of employment will not be punitive. This is a time to formulate safer processes. This is not the time for heavy handed discipline.

Good luck to you and keep your head up.

[klone, MSN, RN]

((gentle hugs))

Take care. We've all been there. Be gentle on yourself.

[klone, MSN, RN]

And just a thought, as someone who does not administer either medication regularly. Is heparin typically given in larger quantities like that (0.5 or 1ml)? If so, could you lobby to get, if not prefilled heparin syringes, at least get 3ml syringes? Or is the dosage of heparin such that it HAS to be in a more exact 1ml syringe?

[bsyrn, ASN, RN]

I am sorry but I do not think "auto pilot" and medication administration should ever be linked together. The 6 rights should be followed every time. I am hoping that some system changes and re education occur. I wish you the best.

[CelticGoddess, BSN, RN]

I haven't seen tuberculin syringes in anything other than 1ml. That is what we use for heparin injections.

My facility uses insulin pens, except in the case of NPH. And I have only had 2 pts on NPH since I started at this facility. Most pts are on Lantus and Humalog. It does help prevent errors between insulin and heparin. And as the Latnus pen is grey/purple and the homolog pen is orange, that helps!

When I have to give NPH and heparin at the same time (very rare, most heparin is given at 2400, while insulin tends to be QHS), I draw up the insulin first. I don't scan the heparin until I have drawn up insulin. Then I scan the heparin and draw it up. It has helped me to not mess up the two.