Insulin pen mixup

[Sothatswhatitis, BSN, RN]

During orientation in September or October I administered a patient Humalog from another patient's pen. I had no idea that blood could back-flow in, so when I realized my mistake, I was shaken up but concluded it wasn't a big deal since the med was right and needle was clean. I didn't report it to anyone; I was afraid being a new grad of getting in trouble and thought it ultimately wasn't a big deal. Not to defend my actions but to report why.

I have just sent an email to my manager explaining and now I'm waiting for the call back... I'm very nervous but glad I decided to report. I had been feeling so guilty and worried since I learned of the blood backflow. I'm still worried because I didn't report it as soon as I learned about it - I was back and forth, thinking the likelihood of harm seems very low based on a little research. I worry I'm not fit to be a nurse for not reporting right away and being so concerned about what reporting it would mean for me.

[JKL33]

Well I think you can feel good about the fact that you've acted according to your conscience in reporting this.

Let us know what you hear back. Good luck ~

[TriciaJ, RN]

Going forward: ANY error needs to be reported immediately. Don't try to figure out how much harm it might do to the patient. Employers should have a non-punitive approach to error reporting, because many errors are systems errors. Reporting errors does not make you look incompetent because everyone knows everyone makes them. It actually makes you look conscientious and honest. If you ever get accused of something you didn't do, your reputation will give you credibility.

I'm glad you finally reported it; living with guilt is horrible and I get that you really are a conscientious nurse. FWIW the patient is probably fine. Hope this all goes well for you.

[Sothatswhatitis, BSN, RN]

Thank you for your responses. She emailed me back saying that such back-flow should not happen "since you are pushing the medication and not aspirating". I responded saying basically: that's what I thought but here is this CDC article that says otherwise. And it probably goes without saying but we will be having a talk in person next time I'm in while she's there (I work nights): probably tomorrow morning.

[Sothatswhatitis, BSN, RN]

After I sent the email with the CDC article link, she got really defensive it seemed to me. She said, more or less:

I don't need to read any article, I know the practice. That's why you were taught the proper way. I was just being nice for you. If it makes you feel better I could give you corrective action for x, y and z.

I'm not sure how to take this. I don't feel my email was threatening, I was just trying to make sure she was aware of the risk, which on her first email it seemed she wasn't. I tried to be respectful in relaying the article, and my purpose was to come clean and make sure the two patients affected get the right care. I don't object to corrective action, as long as it's actually corrective and helps me learn. But I felt threatened on reading it... Obviously you all are reading my abridged (only slightly) version, but some of it is nearly verbatim. I guess I will have a better idea when we talk.

[caliotter3]

Restrain yourself while you are ahead. There are employers who would have shown you the door without blinking once you gave them a med error problem.

[chare]

Restrain yourself while you are ahead. There are employers who would have shown you the door without blinking once you gave them a med error problem.

Particularly one that occurred 8 or 9 months ago.

[JKL33]

After I sent the email with the CDC article link, she got really defensive it seemed to me. She said, more or less:

I don't need to read any article, I know the practice. That's why you were taught the proper way. I was just being nice for you. If it makes you feel better I could give you corrective action for x, y and z.

I'm not sure how to take this. I don't feel my email was threatening, I was just trying to make sure she was aware of the risk, which on her first email it seemed she wasn't. I tried to be respectful in relaying the article, and my purpose was to come clean and make sure the two patients affected get the right care. I don't object to corrective action, as long as it's actually corrective and helps me learn. But I felt threatened on reading it... Obviously you all are reading my abridged (only slightly) version, but some of it is nearly verbatim. I guess I will have a better idea when we talk.

Careful here!

I despise having important convos over email for this very reason. Her reply, bolded above, can actually be read from a still-friendly perspective. The comment about the corrective action plan was rhetorical - she's saying there's no need for self-flagellation.

You have appropriately reported this now, and it is her job to handle it from here.

I agree wholeheartedly with the above, quit while you're ahead. Drop it.

The only thing left to say is, "Thank you for your understanding, I appreciate it. I'm sorry I sent the article; I've been worried about this for months and didn't quite know how to let it go. I've had a chance to put it into perspective and have improved my practice in the process."

No more emails.

[psu_213, BSN, RN]

It is definitely good that you reported yourself....as previously mentioned, in the future report an error when it happens, through the proper channels. One place I worked had a "med error" number, where you could "anonymously" report an error. Otherwise, put in an incident report. That way, the correct people get the report and get to figure out why it happened. Your NM seems to just want to shrug it off, and you are probably best to just let it be. However, there is a risk when giving insulin to a patient from another patient's pen. Did this happen because the pen was poorly labeled? Was it kept in a place that leads to easy confusion about just whose pen it was? Is the safety check (med scanning?) inadequate to determine that the correct pen is being used on a correct patient? If it was one of these things then risk, pharmacy, informatics, etc. will have to work on correcting the issue so the error does not happen again. They are only going to know that it was a problem if it is reported.

You did report the error--great!--now say your mea culpa and move on.