Insulin error

[rn1924]

Today, I was notified by the manager of another floor (a floor that I occasionally float to), that I had been involved in a patient safety issue and they wanted to talk to me about it

long story short, a diabetic patient was admitted from the emergency room with an order for Humalog. When I checked their BS on admission, it was 66, so I gave them some juice and the doctors had me recheck. They also said to give the insulin when the sugar was above 100

I continued to check the BS, alerted them when the sugar was above 100, and gave the medication as ordered (right patient, right dose, right medication, right route) and checks the insulin with another nurse

Checking the sugars after the insulin, the sugar was 129 before my shift ended. Two hours later, after I left, it was 23. The patient was discharged home before I worked the floor the next night.

When the managers called me, they asked what happened, and what my rationale was for giving the medication, and why I thought the patient needed insulin

Now I am worried that I may be at risk for losing my job because I did not catch that the patient should not have been ordered for the medication, nor did I give her any food with the insulin.

I am going to talk with the managers later this week. Does anyone have any thoughts?! Was o ultimately at fault and at risk of being fired?

[Guest219794]

You asked two questions.

Were you at fault? What are your thoughts on that? Reading your post, it is hard to tell. If that is an actual,rather than rhetorical, question, that is a little concerning.

Honestly, the story as you explained it doesn't make sense. What kind of doctor ordered that? Let's put it this way- if the goal was hypoglycemia, there wouldn't be a better way to achieve it. The medication worked exactly as expected with a predictable outcome.

This was clearly a bad order. There were two opportunities to catch it. Either you or the co-signer could have prevented this.

Will you get fired? Ideally this will be an opportunity to look at a system that allowed three people to give the wrong medicine to a patient. The key issue may be education, or communication.

Ideally the patient did well, and you the doc, and the co-signer will all have had a learning experience that will reduce the likelihood of future errors, and the institution will change something.

There is no way to eliminate human errors. They can be reduced, and mitigated, but all humans make mistakes. I suspect that we all make errors that are never caught. For example, even had that patient not, somehow, become hypoglycemic, it still would have been a mistake to give the insulin. But, the mistake would have never been caught. And the process that allowed the mistake would have repeated itself, possibly with worse outcomes.

Look on the bright side. At least this didn't happen. In this case, it truly took a village to harm the patient.

[Guest219794]

Not sure if the link above works right, so, from this source. (Login)

It is worth a read, and addresses the OP.

Quote

Ms. K had recently graduated nursing school. She had hoped to find a job in a pediatrician's office but ended up with a higher paying though less interesting position in a rehabilitation center.

Her plan was to remain at this job until she paid off her student loans, and then move on to something more in line with her original goal. Little did Ms. K know that her first year in practice would be marred by a mistake that would haunt her for the next several years.

Mrs. O, aged 55 years, had been sent from the hospital to the rehab center for a one-week stay following foot surgery. Ms. K was on duty when Mrs. O arrived. After Mrs. O was settled in her room, Ms. K made sure that the order for the patient's pain medication had been sent to the institution's pharmacy. This is where the trouble began.

Unbeknownst to Ms. K, the patient's physician had mistakenly written a prescription for morphine. The physician intended to write the prescription for 50 mg of intramuscular meperidine (Demerol) but incorrectly wrote the order for morphine instead. While the dose was appropriate for Demerol, it was excessive for morphine.

The pharmacist called Ms. K to express concern about the prescription, indicating that the dosage was unusually high for morphine. He added that the pharmacy did not even have that amount of morphine on hand.

The rehab center's policy was that in an event such as this, the nurse should contact the physician to double-check the medication order, but Ms. K was inexperienced and instead of contacting the doctor, she contacted the rehab center's administrative office. An administrator gave Ms. K permission to give Mrs. O the morphine.

Ms. K, several other nurses, and the pharmacist all had to scour the facility to come up with the dose prescribed. The entire supply of morphine from the pharmacy as well as from emergency kits on the patient-care floors was combined into a single 30-mg dose that was given to the patient. The process of collecting the morphine and getting approval had taken a long time, and Ms. K's shift was over. She left without charting the dose or monitoring the patient's respiratory status.

That night, the nurses on duty noticed signs of respiratory depression in the patient but did not report it to the attending physician. At about 6 a.m. the next day, Mrs. O was found unresponsive with pinpoint pupils and barely breathing. She was taken by ambulance to the hospital, and numerous doses of naloxone were given on the way.

At the hospital, it was discovered that Mrs. O had suffered a mild heart attack and was in renal failure due to the lack of oxygen from narcotic-related respiratory depression. She ultimately suffered brain damage and spent six months in the hospital relearning how to walk, talk, eat and groom herself. She will need 24-hour supervision to assist with daily activities for the rest of her life.

When Ms. K heard about what had happened to the patient, she was stricken with guilt and remorse. Every employee in the rehab center was discussing the situation, and Ms. K felt that people were talking about her behind her back, despite the fact that many of those same nurses had taken part in helping put together the dose of morphine.

After Mrs. O was released from the hospital, her husband sought the counsel of a plaintiff's attorney to assess whether they might have grounds for a lawsuit. After hearing the story and reviewing the medical records, the attorney informed them that they definitely had a case against both the physician and the rehab center.

When the rehab center was notified about the impending lawsuit, the administrator called Ms. K into her office and advised her that although she wasn't personally being sued, she and several of the other nurses, as well as the administrator herself, would certainly be called to testify. Ms. K was advised to speak to the rehab center's defense attorney.

With great trepidation, Ms. K met with the attorney, who explained the legal process to her. He told her that she would probably have to testify at both a deposition and at trial, if the case went that far, and that it was important that her story be the same each time.

Ms. K testified that the pharmacist told her that the dose of morphine was high, and that she had contacted administration for approval before giving the patient the medication. When questioned by the plaintiff's attorney, Ms. K was forced to report that she knew the dose was high and could cause respiratory distress. She was embarrassed to admit that she had rushed home before charting the information, thinking that she could just do it the next day.

After two days of deliberations, the jury awarded $3.2 million to Mrs. O and her husband. The jurors found the rehab center liable for neglect and the center and the physician liable for negligence.

Legal background: As part of the verdict, the jurors also had to apportion liability among the parties involved. In cases in which there are multiple defendants, it is common for the judge or jury to apportion the guilt according to who was most at fault.

Although it was the physician who made the original mistake, the rehab center was held most responsible because the order could have (and should have) been questioned before the medication was administered to the patient. The jurors found the rehab center to be 90% liable and the physician to be 10% liable.

[Guest219794]

Been there,done that said:

Knock off the "lose my job " stuff. Your reason for giving the medication is THE DOCTOR ORDERED IT. The critical value of 29 alerted the arm chair quarterbacks. Look 'em straight in the eye and tell them "this is a doctor problem".

What was the insulin type and dose and what was the admitting diagnosis?

You should have considered many factors.. but in the end you were only following orders.

Best of luck with this mess.

Respectfully disagree.

That argument would hold water for a med tech or MA.

What if it was a 5 ml of insulin ordered? Or a K bolus? What do you believe is the role of the nurse in giving medication?

[Been there,done that, ASN, RN]

hherrn said:

Respectfully disagree.

That argument would hold water for a med tech or MA.

What if it was a 5 ml of insulin ordered? Or a K bolus? What do you believe is the role of the nurse in giving medication?

Feel free to disagree. I have held MANY meds, because I felt the doctor had made a prescribing error. It all depends on who prescribes it. If it was the admitting intern, I would go over those orders with a fine- tooth comb. If it was the endocrinologist , I would realize that they knew more about the patient than I did.

[LovingLife123]

May I ask what the order stated? We don't treat sliding scale until it above 150 unless they are on an aggressive sliding scale, then it's 130. I'm not sure why a number of 100 was treated. Especially when you had just treated hypoglycemia.

I'm very confused. Did you document that you called the physician when it hit 100 and they still said to give? And did the order state to treat a blood glucose of 100?

[Guest219794]

Been there,done that said:

Feel free to disagree. I have held MANY meds, because I felt the doctor had made a prescribing error. It all depends on who prescribes it. If it was the admitting intern, I would go over those orders with a fine- tooth comb. If it was the endocrinologist , I would realize that they knew more about the patient than I did.

Well, I figured as much, since you have been there and done that.

But, what you wrote was "Your reason for giving the medication is THE DOCTOR ORDERED IT.", and that it was a doctor problem.

[TriciaJ, RN]

I am completely wigged out about the morphine story. Several nurses and a pharmacist scoured the building to put together 50 mg of morphine? Not one of them said "Wait, what?!" An administrator authorized the dose? I can't even get my head around that whole scenario. I'm surprised the patient even lived.

As far as the insulin, back in the olden days there were only a few kinds. If I had to administer insulin now, I would definitely keep a cheat sheet on me until I got them all straight in my head again. It is a systems error and everyone needs a bit of reeducation. It would be unduly harsh for the OP to get fired and I'm keeping my fingers crossed it won't come to that.

[klone, MSN, RN]

Been there,done that said:

Knock off the "lose my job " stuff. Your reason for giving the medication is THE DOCTOR ORDERED IT. The critical value of 29 alerted the arm chair quarterbacks. Look 'em straight in the eye and tell them "this is a doctor problem".

What was the insulin type and dose and what was the admitting diagnosis?

You should have considered many factors.. but in the end you were only following orders.

Best of luck with this mess.

"Just following orders" will not fly in front of the BON or court. The question is "what would a prudent nurse do?" and the answer is pretty clear in this thread.

I'm not saying that this situation would go before the BON or court, but that I wholeheartedly disagree that the nurse holds no responsibility if the physician gave her bad orders, and then she carried them out.

[Been there,done that, ASN, RN]

hherrn said:

Well, I figured as much, since you have been there and done that.

But, what you wrote was "Your reason for giving the medication is THE DOCTOR ORDERED IT.", and that it was a doctor problem.

Most certainly agree nurses are responsible for doctor's orders, and I always was. My answer was what I thought the OP 's manager wanted to hear. OP has to CY her A at this point.

[Mavrick, BSN, RN]

TriciaJ said:

I am completely wigged out about the morphine story. Several nurses and a pharmacist scoured the building to put together 50 mg of morphine? Not one of them said "Wait, what?!" An administrator authorized the dose? I can't even get my head around that whole scenario. I'm surprised the patient even lived.

There is so much wrong with this morphine story. Is there a typo or was there only 30 mg of Morphine given? Perhaps they meant 30 ml of Morphine since they had to scramble all over the hospital to find enough. Who in their right mind gives 30 ml I'm of ANYTHING??? The "I'll chart this dose tomorrow" line is just too stupid for words. The nurse doing that deserves every punishment possible. Pull that license and send her back to the checkout line.

[TriciaJ, RN]

Mavrick said:

There is so much wrong with this morphine story. Is there a typo or was there only 30 mg of Morphine given? Perhaps they meant 30 ml of Morphine since they had to scramble all over the hospital to find enough. Who in their right mind gives 30 ml I'm of ANYTHING??? The "I'll chart this dose tomorrow" line is just too stupid for words. The nurse doing that deserves every punishment possible. Pull that license and send her back to the checkout line.

I originally missed that she didn't even chart the dose given before she left. The other thing I missed was that they pulled morphine out of emergency kits. They keep morphine in emergency kits in a nursing home? The whole story strains credulity.

[blackmamba123]

rn1924 said:

Today, I was notified by the manager of another floor (a floor that I occasionally float to), that I had been involved in a patient safety issue and they wanted to talk to me about it

long story short, a diabetic patient was admitted from the emergency room with an order for Humalog. When I checked their BS on admission, it was 66, so I gave them some juice and the doctors had me recheck. They also said to give the insulin when the sugar was above 100

I continued to check the BS, alerted them when the sugar was above 100, and gave the medication as ordered (right patient, right dose, right medication, right route) and checks the insulin with another nurse

Checking the sugars after the insulin, the sugar was 129 before my shift ended. Two hours later, after I left, it was 23. The patient was discharged home before I worked the floor the next night.

When the managers called me, they asked what happened, and what my rationale was for giving the medication, and why I thought the patient needed insulin

Now I am worried that I may be at risk for losing my job because I did not catch that the patient should not have been ordered for the medication, nor did I give her any food with the insulin.

I am going to talk with the managers later this week. Does anyone have any thoughts?! Was o ultimately at fault and at risk of being fired?

First of all, anytime you are the one making the call to administer something, you will be held responsible. Though providers write the orders, we are tasked with questioning something that doesn't make sense or is not in the best interest of the patient given your assessment/patient's presentation.

Secondly, it sounds like your manager is trying to gather all of the information about what happened, and possibly discipline you, require that you remediate on insulin (you should even if it's not required), diabetes, etc. or both. But getting fired would be extreme, especially if you don't have a pattern of errors or other issues at your facility, and the patient is OK. However, like the other poster said, it's impossible to know what your manager has planned.

That being said, we've all made mistakes. If you run across a nurse who says they haven't they're probably lying. Hopefully your patient is doing well. Throughout the course of this though, be honest with your employer and yourself, sincerely apologize, and forgive yourself as well. Learn from this mistake and move on. Going forward though, if something doesn't seem right, ASK. It can definitely save you a lot of grief, and most importantly, help you give safe care. I hope you update us on how things went, and that it goes well for you.