insulin med error

Nesher, BSN, RN · Jan 4, 2006

I have several mistakes that I always tell the new grads I precept - it takes me off the pedestal and makes me seem human.

The first was when I was several months into a new job/state. It was nights of course I was in charge - I with several months experience total. At the end of report at 11:30 I was called into a patients room. She was in the bathroom, which looked like a blood bomb had gone off. Blood everywhere. I don't know how she did that - the blood was on all 4 walls - waist high. She was covered - the bedroom and bed looked a massacre had taken place. She had had a vag bleed - cervical Ca. At any rate, stat hct, etc etc, endless cleanup, I was to say the least a tad frazzled when I finally had her settled. My next patient called for me and asked for benadryl. She was a sickle cell patient - frequent flyer and the narcs made her itchy. I grabbed the med and gave it to her. This before the days of PYXIS and all the meds were jumbled together in a bin - all their prns etc. As I walking out the door to get something else for her, she sat straight up and started to seize (grand mal) as well as projectile vomit - all the way across the room.

What had I given her? I can tell you there is a difficult to breathe feeling as well as that gnawing knowledge that I must have given her something bad. I actually went back into the med room and dug through the garbage - I was sure I hadn't!

Clearly I had. It turned out I had given her compazine instead of benadryl - the containers were the same size and the print on each of them was in black - thus my mistake - I had in my frenzied state from the other patient and her bleed out had not looked closely. Now granted it should not have been in her bin since she had an allergy to it, but it doesn't excuse my not checking closely. She ended up being fine - the hospital paid for her admission and I was forevermore uncomfortable around her. This wasn't my last med error that year though.

The second biggie I did was with a 19 year old with neurofibromatosis (spelling) which had become cancerous - She had a huge inoperable abd tumor that made her look 9 months preg. This tumor had also wrapped around her ureters and among the many problems she had was enormous pain. She had a forest of IV pumps in her room on both sides of the bed. Several pumps were hooked to the caths keeping her ureters infused with medication - I don't recall the purpose) - she also had antibiotics, IVF, 2 PCA's one with MS one with versed and another pump for her epidural gtt. This was before the days of locked epidural specific pumps. She had come racing back from a procedure and the epidural bag was empty - so I changed it quickly and got her back into bed - an arduous process. Her pain kept increasing all evening.

It wasn't until the next day when I go to work that I was told what I had done...I had hung Vanco instead of whatever it was she had for her epidural - talk about your heart sinking to the floor. It turns out a person can get Vanco into the epidural space, and because the gtt was at a slow rate she didn't exceed the amount allowed. I was her primary nurse so I continued to care for her until her death. I felt pretty bad about contributing to her pain though...

Those two mistakes occurred when I was a newbie and I recognize their value in teaching me to slow down - take the time to look at what you are giving and to remember you are a human and to be thankful when your screwups don't permanently harm someone.

Constance7 · Jan 4, 2006

Breathe! You did not do anything that any other nurse has not done. It was an honest mistake and you took the right steps to right the wrong. As nurses we all have made a med error or two. It sounds as if your patient was fine and there was truly no real harm done as a result. I do not believe that you will lose your job. You probably will get spoken to and the best you can do is admit the mistake and I promise you that this is a mistake that you will never make again. Since it was regarding insulin you will double and triple check before administering. And something to remember is this- IT DOES NOT MAKE YOU A BAD NURSE. Just chalk it up as lesson learned. Good luck!

Tweety, BSN, RN · Jan 4, 2006

Welcome to the world of being human.

Forgive yourself. Learn from it, find out where in the med-giving process it broke down and you made the error.

More than likely you won't loose your job over this one, as it's your first one and the patient had no ill effect.

Best wishes and I hope you sleep well.

jimthorp · Jan 4, 2006

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Daytonite, BSN, RN · Jan 5, 2006

Whether or not you lose your job is going to be almost totally dependent on who ever is your manager. Some managers will go balistic and terminate over something like this; most won't. However, you will have to answer for your mistake and you put that process into motion. You did not mention what you learned from this mistake. I'm sure if it wasn't a question posed on the incident report you had to fill out, it will come up in a conversation with your manager. So, the question is what are you going to do to prevent this from ever happening again?

jimthorp · Jan 5, 2006

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pugmum · Jan 5, 2006

i have been a nurse for almost one year- i just had a major med error this morning- i gave the wrong insulin to a patient...i gave him 32 units instead of 18- my heart sunk and i have had that nautious feeling all day. i reported it to the dr right away and also filled out a med error report sheet. the residents blood sugar was over 200 this morning, then i had to go home and sleep- i worked the night shift. has anyone done this before?? will i lose my job? thank goodness the patient is ok.....

the previous posters have given good advice - and as far as anyone else making med errors, i think stats would show that most nurses have made one error or another throughout their careers.

errors are just that...errors. they are accidents, not done on purpose. you did not intentionally set out make this error. the most important thing you could have done, you did. and that was to report it right away.

errors like this etch themselves on your mind, and will make you more cautious in the future...its the school of hard knocks, but lessons learned are definitely remembered.

congratulations on reporting this so promptly. you have demonstrated your professionalism and your concern for your patient as your priority. med errors are sometimes due to a system fault, and sometimes due to nurse inattention. regardless, it is important to identify what the contributing factors were, and i hope you included them in your report.

i've no doubt you will continue to do well...i wish you all the best in the future! :)

**RosesrReder, BSN, MSN, RN** · Jan 5, 2006

I am not a nurse, but you seem to have gotten excellent advice/encouragement above. Best wishes to you in the future and put this behind you.

GooeyRN, ADN, BSN, CNA, LPN, RN · Jan 5, 2006

We all make mistakes. You did the right thing and there wasn't any patient harm. Try not to feel bad. (Easier said than done.)

UM Review RN, ASN, RN · Jan 5, 2006

It happens to everyone. You did the right thing by reporting the error promptly so it could be fixed.

If you want to feel better, know that you're in some very good company. Click on the link to read a thread about Med Errors.

https://allnurses.com/forums/f8/med-errors-86200.html?highlight=medication+errors

mona b RN, BSN, RN · Jan 5, 2006

I have been a nurse for almost one year- I just had a major med error this morning- I gave the wrong insulin to a patient...I gave him 32 units instead of 18- my heart sunk and I have had that nautious feeling all day. I reported it to the Dr right away and also filled out a med error report sheet. The residents blood sugar was over 200 this morning, then I had to go home and sleep- I worked the night shift. HAs anyone done this before?? Will I lose my job? Thank goodness the patient is ok.....

You have gotten really good advice here and kudos to you for being honest.:) I am sure you have learned from this and you will build your confidence back up.:icon_hug:

Good Luck!