I Have to Find Another Job ......

TheCommuter, BSN, RN · Oct 31, 2008

Was this a serious med error in Asst living to give 2 extra units for a 250 blood sugar? I am so crushed.

Although you were acting in the best interest of your patient, you are to NEVER give a patient extra medication without a physician's order to cover you. If you did not have a doctor's order to administer the 2 units in addition to the sliding scale order, you were not supposed to have given the extra insulin.

In addition, you documented your intervention in the nurses notes for all to see. Unfortunately, the state might read these notes at a later date and consider your action as "practicing medicine without a license." The bottom line is that you did not have an order to give those extra units of insulin. If you felt your patient needed more coverage than the sliding scale order, the best course of action would have been to telephone the doctor, report the blood glucose reading, and perhaps obtain a one-time telephone order to give the additional 2 units.

I might feel that my patient with a mild headache could benefit from some Ibuprofen. However, I'd never give it if there's no order to cover me. The doctor is paid a handsome six-figure salary to decide the patient's med regimen. I am paid a fraction of what the doctor earns because those decisions are not within my scope of practice. Good luck to you!

lunden · Oct 31, 2008

i felt so bad reading this. it seems that should have been ok, but lesson learned. sometimes things happen 4 a reason. when 1 door closes another always open's up and sometimes better than the first. good luck:nuke:

CaroleN199 · Oct 31, 2008

Thank you for the advice. Yes, I do know for sure NEVER EVER give any medication without a doctors VTO or script if not on the MAR per physician's orders.

This certainly is a lesson learned. With the economy, in my area, there is a freeze on in hospitals and nursing homes to hire nurses.

Again, thanks ................

pagandeva2000, LPN · Nov 1, 2008

thank you all for listening to my plight. i was called into the office at lunch time and told i had to be let go. i worked in asst. living. the residents are very much oriented x 3. i know we have rules that must be followed and i had no problem with that. when i first went there i was told i could be hired as a med tech. when i appeared for the interview two months ago the facility administrator hired me on the spot as an lpn at $21.00/hr. i had orientation for a couple of weeks with 8 different people. instead of one to mentor me and had no consistency. everyone had their own way and their own rules and told me this is what they did. so, i took a little from each one and then went on my way to be on my own as a new graduate. i had to apologize to a resident last week for an aide telling a dear woman that she was disgusting when she went in to clean her colostomy bag. just today i had to apologize to another resident who is on hospice for waking up the aide during night shift at 1:00 am wanting prune juice from her fridge and tylenol. resident was brought the tylenol and not asked what the pain was, the scale of pain or where the pain was located. an emt was on and told her to be quiet and get back to bed it was 1:00 am. i had found out after being hired that there were 2 med techs there in their early 20s. since i was hired they had zero hours. also, the one was reinstated after she had been relieve of duties due to disciplinary measures.
[color=sienna]i had a resident who has a yo yo blood sugar. she had a b/s of 80 at 5:00 pm and refused 5 units of insulin. after dinner i took b/s again and it was 87 she refused insulin. the mar stated at 8:30 hs to give 2 units. at that time her b/s was 250. since she had no coverage at all at dinner i gave her 2 units plus 2 units for coverage. the other patients in asst. living are sliding scale. i had to leave and there was no nursing coverage overnight. i wrote this up in the notes what i had done and why. the next day i was told it was a very serious med error and that the family had to be called. there were no side effects at all and it was 2 extra units on a nursing judgement that i made. why then was i allowed the next day to work and give out all the medications on the 2nd floor then called down and told to sign a form and they had to let me go. was this a serious med error in asst living to give 2 extra units for a 250 blood sugar? i am so crushed.
i loved these people and had grown fond of them. i truly care about my profession and made a bad call. the don said i should have called her at home or call the doctor. well ok so now i have lost my job that i was just settling into. was this really grounds for letting me go? just like that?
the people really liked me and i cared about them.
oh, the don told me as she walked me out the door that she liked me as a person and would
write me a good letter of recommendation for another job if i needed it. she told me she would
not report me to the state regarding my licensure. ??? am i the only newly graduated nurse to make
a bad decision like this. is this what happens when you are on the job and new??
thank you for you expert nursing advice.......

first, i am sorry you were terminated. i am curious, though...you mentioned that the patient's blood sugar was 80mg/dl and the patient has an order for 5 units of insulin? what type of insulin was this? i guess i am trying to understand how or why a glucose reading that is average would need 5 units at all, or maybe i am reading this wrong. my hospital usually would have ordered two units once a person is at least over 140mg,dl. one thing you need to know for sure, is that if you work at another alf, and are alone, who do you contact in case of an emergency or for further nursing instructions/intervention? here in ny, an rn has to be available at least by telephone. maybe she could have made this order more clear to you, and then, of course, you would call the physician for clarity and direction. know the policies about taking phone orders in next place of work.

any nurse that says that they have not made an error is either unaware that they actually made one, or is not being that truthful. it is that some or even most mistakes are not reported or covered up, somehow. it happens. as thecommuter stated, this is practicing without a license and once it is documented, it can't be retracted. it left the don in a difficult position. at least she stated that she would write a letter of recommendation (which i would obtain sooner than later). take a few days to nurse your wounds and get on the bandwagon to look again for another position. good luck!

moonchild20002000 · Nov 1, 2008

I am sorry this happened to you.I would get a letter of recommendation as soon as possible for your next job.

If faced with a similar situation in the future,call the doc. Even when a patient refuses meds (and I would at 80) as nurses we can't adjust the dose.I think the way it was

charted is what led to your termination.

We have all made mistakes,your patient was fine,the important thing is to learn

from our mistakes.

Good luck in the future,you will get through this.

caliotter3 · Nov 1, 2008

I also recommend getting that letter of recommendation now. Do not delay. Someone offered to provide a good reference for me and later started to do the opposite. Get that letter now and don't give her time to change her mind.

pagandeva2000, LPN · Nov 1, 2008

I am sorry this happened to you.I would get a letter of recommendation as soon as possible for your next job.
If faced with a similar situation in the future,call the doc. Even when a patient refuses meds (and I would at 80) as nurses we can't adjust the dose.I think the way it was
charted is what led to your termination.
We have all made mistakes,your patient was fine,the important thing is to learn
from our mistakes.
Good luck in the future,you will get through this.

If I were a savvy patient, I would not have wanted 5 units of insulin at 80mg/dL, either. What I am questioning is the order itself...that alone would have made me want to call the doctor and RN for clarity.

Sometimes, we learn better from our mistakes than we do from our successes. I am just grateful that the DON did not report it to the state and at least wants to give the OP a chance somewhere else.

12breakfree · Nov 1, 2008

I'm not a nurse yet, just a nursing student and I'm learning as I go but why giving insulin when her BS was below 110? From my understanding, you give insulin when it's higher than 110 and above according to the sliding scale or based on their accucheck. Am I right? I'm started to give out meds but like I mentioned I learn as I go.

However, I agreed with other here that you should call the doctor even though it is 2am in the morning. Boy, I didn't know they take this seriously. You did mentioned that they had to call the family, maybe the BS crashed after you gave her extra 2unit? I mean if not to say the least but if that wasn't happening, they wouldn't be letting you go, right?

TheCommuter, BSN, RN · Nov 1, 2008

Boy, I didn't know they take this seriously. You did mentioned that they had to call the family, maybe the BS crashed after you gave her extra 2unit? I mean if not to say the least but if that wasn't happening, they wouldn't be letting you go, right?

They're letting her go because she documented in the nurses notes that she gave 2 units of insulin without a doctor's order. Surveyors from the state regard this action as practicing medicine without a license, which could get the facility in trouble if the nurses notes are reviewed during a chart audit by the state.

The patient certainly didn't crash due to receiving 2 extra units of insulin. The decision to let the nurse go has very little to do with patient safety, and more to do with the politics of covering the facility's butt. You'll understand more about healthcare facility politics when you start working as a nurse.

morte, LPN, LVN · Nov 1, 2008

If I were a savvy patient, I would not have wanted 5 units of insulin at 80mg/dL, either. What I am questioning is the order itself...that alone would have made me want to call the doctor and RN for clarity.
Sometimes, we learn better from our mistakes than we do from our successes. I am just grateful that the DON did not report it to the state and at least wants to give the OP a chance somewhere else.

i am hazzarding a guess that the 5 units was humalog or some such very quick acting insulin given pre meals.....good call on the patients part to decline....i have to assume that this patient had NO sliding scale....when the OP states that OTHER residents did....this is what "gotcha" ....call those docs!!!!

pagandeva2000, LPN · Nov 1, 2008

i am hazzarding a guess that the 5 units was humalog or some such very quick acting insulin given pre meals.....good call on the patients part to decline....i have to assume that this patient had NO sliding scale....when the OP states that OTHER residents did....this is what "gotcha" ....call those docs!!!!

Usually for coverage, it would be Humalog or Regular insulin, which is why I would have questioned the order to begin with...for 80mg/dL, what reason would the patient need coverage? That plagued me each time I read the post, because I never saw an order for coverage for an average glucose level. This is where I would have called the doctor to be enlightened, if nothing else. He may have had a reason that made sense, but I would have documented what the doctor said, why, etc...and if he didn't respond, I would have documented how many times (and the exact times) I called. No response...no insulin. I would have circled the signature of the MAR explaining why it wasn't done. This is why I would always want to know who do I call if I were alone...because I would have been documenting both names...the physician as well as the RN...how many times I called and why something wasn't done. Of course, this is hindsight for the OP, but this is one of the reasons I value these forums so much. We learn from each other. There are so many things that made me take a double take while working-not so much because I had experience in each situation, but because I would say to myself "Hey...I read of a similar situation in allnurses and ..." which would make me make a different judgement.

I just want the OP to know that I am not trying to say anything to make her feel bad...that is not it. All nurses encounter things where we are just not sure what to do. In addition, we learn from our mistakes. What this is doing is making my mind work by saying "well, if I encounter something similar, maybe an option would be this..."