Do you think this med error was preventable?

[pn2rn08]

Hi all. I recently made a med error due to an order that had perimeters added to it. 10 units of insulin @ dinner time, Hold for FS

[klone, MSN, RN]

It would have been preventable by reading the orders prior to administering the medication.

I don't work with IDDM pts. enough to question that order, but I always make sure to double check orders before administering insulin. I would assume that doctor has a good reason for writing it at

(psst...it's "parameters" not "perimeters") :)

[pn2rn08]

Yes I do agree with double checking would of helped prevent it. I'm usually pretty good about double checking everything as well as writting down side notes on my paper, that night it was crisis after crisis at the start of shift...lesson learned SLOW down during med administration despite all that's going on.

LOL thanks of the spell check

[klone, MSN, RN]

Maybe because I *don't* work with IDDM pts very often or administer insulin, it's one of those drugs that I always always always double check before giving. I'm unfamiliar enough with it to be afraid of it.

[April, RN, BSN, RN]

Maybe it would be better to have this patient on a sliding scale instead of standing orders for insulin?

[pn2rn08]

Good suggestion April. I may suggest this next, once we get a feel for her baseline. Now that she is in a "controlled" enviroment as far as diet goes she may no longer need the standing doses. I have heard about there being controversy in regards to keeping or discarding sliding scales but haven't seen the evidence yet. Another research item to put on the "to do list" lol.

[kcochrane]

Were the parameters written on the MAR in RED?..... Either that or they should have been circled in red on the MAR.

If so, use it as a lesson learned. Read your MAR each and every time before you administer a med. Been there, done that. There is no other way to prevent a med error like that. :)

[ChristineN, BSN, RN]

Yes I do agree with double checking would of helped prevent it. I'm usually pretty good about double checking everything as well as writting down side notes on my paper, that night it was crisis after crisis at the start of shift...lesson learned SLOW down during med administration despite all that's going on.

LOL thanks of the spell check

My hospital writes orders like that all the time. Typically we don't administer insulin unless the pt is 121 or above. I agree with the previous poster that this could have been prevented by re-reading the MAR prior to administration.

[Sparrowhawk]

Probably preventable...but be careful. Insulin errors cause terminations!

[morte, LPN, LVN]

Hi all. I recently made a med error due to an order that had perimeters added to it. 10 units of insulin @ dinner time, Hold for FS

is this a paper MAR? and was this ADDED to the original order, or was the order completely rewritten?

[jerenemarie]

I always, always have my insulins double checked by another nurse...double check the syringe & the order too!

[realnursealso/LPN, LPN]

"10 units of insulin @ dinner time, Hold for FS