insulin med error

Bird2 · Jan 5, 2006

Med errors do create an awful gut feeling but all of us have made them. My first known error was giving an extra long acting Morphine instead of a short acting breakthrough dose. That was the worst day of my life. The pt survived and I got a learning experience that I will never ever forget. I will never give Morphine without another nurse checking it and I bet you will be extra cautious on insulin. Good for you and your honesty.

ColdFusion · Jan 5, 2006

Med errors are much more common than anyone will admit, you did the right thing, learn from it and go on....

We have to co-sign all insulins where I work.

flyladynurse · Jan 6, 2006

Thanks for all of the encouragement. I did learn a lot from this error, and have been extra cautious ever since. Interestingly enough, this patient saw the dr the next day and his insulin was actually increased to almost the amount that I had given him, because he had been having high blood sugars, Not that it lightens my error at all, but no harm done to the patient and a good learning experience not only by me, but a warning to the other nurses in our facility on how quick an error can happen!!!

AuntieRN · Jan 6, 2006

I am just a student, but, I thought insulin had to be checked by 2 licensed personel to avoid these kinds of errors. I do not mean to sound sarcastic I am just wondering for my own future reference.

jimthorp · Jan 6, 2006

I am just a student, but, I thought insulin had to be checked by 2 licensed personel to avoid these kinds of errors. I do not mean to sound sarcastic I am just wondering for my own future reference.

Where I work, no co-signing or checking is required.

oneLoneNurse · Jan 6, 2006

Thanks for all of the encouragement. I did learn a lot from this error, and have been extra cautious ever since. Interestingly enough, this patient saw the dr the next day and his insulin was actually increased to almost the amount that I had given him, because he had been having high blood sugars, Not that it lightens my error at all, but no harm done to the patient and a good learning experience not only by me, but a warning to the other nurses in our facility on how quick an error can happen!!!

Many years ago when I was orientating to a unit with the DON I gave the wrong patient someone else's insulin. The DON watched me do it.

flyladynurse · Jan 6, 2006

I wish we had to double check it, even though it would be more time consuming. The policy to double check is only a facility policy- it varies from place to place

oneLoneNurse · Jan 7, 2006

I wish we had to double check it, even though it would be more time consuming. The policy to double check is only a facility policy- it varies from place to place

I just began work on a psych unit, we don't have to get it double checked. BUT I think I will insist on it, no matter how much time it takes. They can label me an old granny, for all I care. Certain things I like about regulations.

Pekoe-RN · Jan 9, 2006

Good advice from Daytonite - What was Learned? I was told that just before I started, a new grad had made a med error. All the nurse supervisor said to him was - will this ever happen again?!? And then she crumpled the report. As other posts have stated - we are all human, and humans are not perfect. But we are in a profession in which mistakes can have significant impact, and we feel that impact so profoundly. If we didn't, well ...... we wouldn't be human, would we?

Good luck to you whatever happens. We are all with you.

SFCardiacRN · Jan 9, 2006

Good for you for reporting it. Otherwise you would have made 2 mistakes!

the jennerator · Jan 17, 2006

Don't beat yourself up. You will make many mistakes in your career, we all do. You did what you should, you notified the doctor immediately and intervened to keep the patient safe. Accept accountability for your mistake with your boss and provide him/her with an action plan of how you will prevent yourself from making this type of error again. One thing I've learned about med errors is that you'll never make the same mistake twice. It is a good practice to double check insulin with another RN, even if it's not your facility's policy. Your first few years of nursing are horrible. I promise it gets better, just hang in there. Unfortunately even very experienced nurses make errors. Try not to rush too much when administering meds and follow the 5 rights. Hang in there!

PickyRN · Jan 17, 2006

I am just a student, but, I thought insulin had to be checked by 2 licensed personel to avoid these kinds of errors. I do not mean to sound sarcastic I am just wondering for my own future reference.

I have seen both sides. I worked at a nursing home and we didn't have to have two people sign off on it. I felt that this was ok, because nobody was on a sliding scale, and we gave the same dosages all the time (even now, seven months after I left, I can remember that person A got 10 units, person B and C got 5 units, all Novolin 70/30 with supper, and person D got 30 units of Lantus at HS.).

Now I work at a hospital and we have to have the dosage checked off by two personnel (one can be a tech). I think it's a good check, because with sliding scales, and always getting different patients, it is too easy to mess up.

Biggest med error I have had to date: A dialysis pt's fistula wouldn't quit bleeding so the dr prescribed 12.5mg of protamine sulfate IVP. It came up from the pharmacy in a 50mg/ml vial. I did not double check the dosage, and ended up giving the entire 50mg vial. Thankfully it was just protamine and not something deadly (like 4x the dosage of insulin may have been), but it was certainly a cold dishcloth to the face. Now I triple check the dosage to make sure.

A nurse I was working with a few months ago was giving meds at HS, drew up the scheduled 5000 units of heparin for the pt in bed B and promptly gave it to the pt in bed A. oops! Everybody turned out ok, though, because he NOTIFIED everybody right away. That's the main thing to remember: yeah, you might lose your job if people find out, but the pt might lose their life, and that's way more important. If you make a med error, don't cover it up. Tell the doc at the very least.

Picky