Do you think this med error was preventable?

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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

Specializes in med/surg, tele, OB.

Both hospitals I have worked at require insulin to be double checked and signed prior to giving.... And when I worked med/surg that was a pretty common order with my docs.

Thankfully it all turned out okay and you learned something...:o

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Ok So I realized I incorrectly worded the title of this thread however can't edit it now. I know it was preventable so I guess my question should of been...what would you have done when receiving the order parameter? Made suggestions to the MD or just considered it normal? I've been a nurse for 3 yrs of LTC as well as med surg & never did I come across parameters like that so I guess that's why I'm questioning it. So I'm interested to see what others come across in practice as well as decision making, thank you all!

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Were the parameters listed in the order on the MAR or on a different page or different lines? I know where I work, by the end of the month, MARs can get pretty confusing. We have some people with multiple pages and we aren't allowed to write in red or highlight DCd orders, per state contract. If it was a situation like that, I think the facility and/or person taking off the order shoulders some of that responsibility. It sounds like a great learning opportunity and I'm glad nobody was hurt and you weren't in trouble. Thanks for sharing!

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I wouldn't have questioned it. I've seen too many deviations on parameters based on a patients own health. If it is a patient that is known to drop at night, then it would be normal to change the parameters.

Should have added that there is nothing wrong with questioning. I've just seen it all, so I guess I'm not surprised when I see "different" parameters.

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Where I work , 2 always check the dose, the order, and the expiration date of the bottle.

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Specializes in One day CCU maybe!.

What kind of insulin was it? If it was Lantus I probably wouldn't have given it unless they were over 120 just out of habit. Even if there was no rule or perameters saying to hold if

Even when there are no parameters given, I usually hold insulin when its less than around 140 unless they get their tray directly after the accuchek. Our perameters on sliding scales at our hospital start at 151. No insulin is ever given if its less than that unless its Lantus or something. But for long time diabetics, if there are no parameters, I'll just ask - "Do you want me to hold your insulin?" Insulin is too dangerous IMHO to give if my gut tells me not too. What if they get nauseous and decide not to eat and I've already covered them???

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