med admin mistake...confused...

DG5 · Jun 25, 2005

That's just nuts! How can she be donning a nurse's uniform?? WOW. You never know if she is making any other ditzy mistakes, maybe she isn't even aware of making them! Wow. :uhoh21:

begalli · Jun 25, 2005

1. is there even a syringe that holds 130ml??? i mean one that you would commonly use to admin meds?

i'm sure a syringe that size exists, but not for administering insulin!

2. im just a nursing student, but ive always been taught that the first thing you do before admin. meds is check the mar with the dr.s orders...or is this not common practice?

first, don't minimize yourself by saying you're "just" a student. you are smart...take credit for it!

yes, it is fairly routine to check orders for accuracy of transcription. especially if there is any question as to the drug, dose, time, etc.

3. the agency nurse was a seasoned nurse...she is in her mid 50s and has been practicing since her early 20's (no breaks)...or so she said...why didnt that automatically send up a red flag??

you got me there.

4. i was under the impression that insulin needles were usually only 1ml...would there ever be an incident that you would give such a large dose?

we use tb syringes to administer insulin sq or iv. i have had patients in the icu on insulin drips up to 40 or more units/hr (transplants on epi and steroids). however, i don't think i've ever given anyone more than 10 units sq or iv push - not that it probably doesn't happen, but in our icu if a patient needs that much insulin, they are on a drip with hourly boluses if needed.

5. to me this seems like such an odd mistake....dont you think that a nurse practicing for that long would have caught a mistake like that?

seems like there must be more to this or a misunderstanding? i can't imagine a seasoned nurse preparing to give 130 ml of insulin. right? i mean even you, "just a student" knows that there's something wrong with that.

it was totally her responsibility to recheck that order. i think i would laugh if i saw 130 ml insulin on my mar!! as nurses, we have a duty to our patients to make sure what we do is safe for them - that means questioning weird orders. just because a doctor writes an order doesn't make it right 100% of the time.

GrnHonu99, RN · Jun 25, 2005

That's just nuts! How can she be donning a nurse's uniform?? WOW. You never know if she is making any other ditzy mistakes, maybe she isn't even aware of making them! Wow. :uhoh21:

i guess...i thought it was an obvious mistake but then again i'm a first semester nursing student so i thought maybe i just didnt realize or ther ewas something that i didnt know..ie..maybe some pts for some reason got HUGE insulin doses...who knows....just seems like someone who has been a nurse that long wouldnt make a mistake like that...like i said she would have given it to the pt if the charge nurse hadnt walked in...that is if she ever found her 130 ml syringe...

jeepgirl, LPN, NP · Jun 25, 2005

HI all...
I heard a very disturbing story tonight and thought you guys would have some input on the idea....
My mom works at a local hospital here in my area......anyway...she said that there was an agency nurse on her floor the other night (i only say agency just to point out that she wasn't familiar with this nurse since she was a temp)....well anyway..
the charge nurse went into the med room and found this nurse searching for something...she said that she had numerous med drawers out and syringes all over...sooo she asked her what she was looking for...well...and this is the scary part...
she says "im looking for a 130ml syringe so that i can give insulin to my patient".... well the charge nurse knew immediately that something was wrong...seeing as though 130 ml of insulin is enough to kill someone...but before passing judgement the charge nurse asked her, well is this a brittle diabetic? or is the patient really heavy? the agency nurse answered "no" to both...
come to find out, the nurse from the previous shift took the order off wrong and instead of 3 ml she had written 130 ml....HUGE DIFFERENCE...ok. so not the agency nurses fault technically...BUT...she didn't check her MAR with the DRs orders and the charge nurse confronted her about it and asked her why she did not check before administering meds...the agency nurse's response was "well its not my fault, i didnt write it, why should i have to check it"....
so i have a few questions....
1. is there even a syringe that holds 130ml??? i mean one that you would commonly use to admin meds?
2. Im just a nursing student, but ive always been taught that the first thing you do before admin. meds is check the MAR with the dr.s orders...or is this not common practice?
3. the agency nurse was a seasoned nurse...she is in her mid 50s and has been practicing since her early 20's (no breaks)...or so she said...why didnt that automatically send up a red flag??
4. I was under the impression that insulin needles were usually only 1ml...would there ever be an incident that you would give such a large dose?
5. to me this seems like such an odd mistake....dont you think that a nurse practicing for that long would have caught a mistake like that? I mean 3ml and 130 ml is a HUGE diff...if the charge nurse wouldnt have caught her then the pt would have been dead...although i cant imagine trying to get a 130 cc out of those little insulin vials.....wouldnt it take like a ton of vials to even make 130 cc? it just seems like such an obvious mistake..maybe im missing something? confused... :uhoh21:

Well... when I am giving meds, I do not always check the MAR and the doctors orders before giving the meds. I do sometimes though. But, that is why there is a "MAR verification" area on our MARs... someone has verified the MAR and the doctors orders before I get to it. If a new med is added during the shift, one nurse transcribes and the other checks the transcription against the order in the chart and cosigns it. Whenever the new MAR prints on my shift, I then go and do an audit myself and check the MAR against the orders for the next shift. We have routine meds, and our weights are on our MARS. In peds, I can usually estimate our usual meds that we give - Rocephin, Motrin, Tylenol, Amp, Claf, etc - per weight. I keep a drug book right by because I am kind of tense about checking dosages and weights... if I haven't given the drug a lot, I always like to look it up and double check the recommended dosages and side effects. That's one of our responsibilities as nurses... knowing the meds your giving.

HOWEVER...

If I ever get a dosage on an MAR that I question... and 130 ML of insulin would do that... I would go directly to the chart, verify, and then call the doctor to get a clarification. That is an obvious error!!!! And if the doctor continued to order this drug in this manner... I would refuse to give the med. First of all, you administer insulin in units, not ML. You use an insulin syringe to draw it up... which is marked in units, not ML. I don't give insulin all that much on my floor (peds) but even 130 units seems like a lot. However, some more experienced nurses who do insulin could verify that either way.

The biggest syringe I have seen is a 60ml. How could you give that much insulin sub-q? I guess you'd probably have to IVPB that 130ml of insulin!! LOL!! When I was in school, our instructors told us that if we were drawing out of multiple vials, there was a big problem... and we needed to check our orders / dosages / MARs and our drugbooks. And I do... if I ever need to draw out of more than one vial for anything, I always double check. I feel that it is very important, especially in Peds - our dosages are sometimes a fraction of what an adult would get!

GrnHonu99, RN · Jun 25, 2005

seems like there must be more to this or a misunderstanding? i can't imagine a seasoned nurse preparing to give 130 ml of insulin. right? i mean even you, "just a student" knows that there's something wrong with that.

it was totally her responsibility to recheck that order. i think i would laugh if i saw 130 ml insulin on my mar!! as nurses, we have a duty to our patients to make sure what we do is safe for them. just because a doctor writes an order doesn't make it right 100% of the time.

i would have though so too..if my mom hadnt witnessed it first hand i dont know if i would have believed it....it just makes me wonder what other mistakes she is making...more than anything it kinda upset me...my mom is due to have major surgery there in about a month and she will be on that particular floor as it is an orthapedic floor and she is having a total hip replacement....oh and my mom is diabetic...so it just kinda scares me...

Ms.RN · Jun 25, 2005

hi all...
i heard a very disturbing story tonight and thought you guys would have some input on the idea....
my mom works at a local hospital here in my area......anyway...she said that there was an agency nurse on her floor the other night (i only say agency just to point out that she wasn't familiar with this nurse since she was a temp)....well anyway..
the charge nurse went into the med room and found this nurse searching for something...she said that she had numerous med drawers out and syringes all over...sooo she asked her what she was looking for...well...and this is the scary part...
she says "im looking for a 130ml syringe so that i can give insulin to my patient".... well the charge nurse knew immediately that something was wrong...seeing as though 130 ml of insulin is enough to kill someone...but before passing judgement the charge nurse asked her, well is this a brittle diabetic? or is the patient really heavy? the agency nurse answered "no" to both...
come to find out, the nurse from the previous shift took the order off wrong and instead of 3 ml she had written 130 ml....huge difference...ok. so not the agency nurses fault technically...but...she didn't check her mar with the drs orders and the charge nurse confronted her about it and asked her why she did not check before administering meds...the agency nurse's response was "well its not my fault, i didnt write it, why should i have to check it"....
so i have a few questions....
1. is there even a syringe that holds 130ml??? i mean one that you would commonly use to admin meds?
2. im just a nursing student, but ive always been taught that the first thing you do before admin. meds is check the mar with the dr.s orders...or is this not common practice?
3. the agency nurse was a seasoned nurse...she is in her mid 50s and has been practicing since her early 20's (no breaks)...or so she said...why didnt that automatically send up a red flag??
4. i was under the impression that insulin needles were usually only 1ml...would there ever be an incident that you would give such a large dose?
5. to me this seems like such an odd mistake....dont you think that a nurse practicing for that long would have caught a mistake like that? i mean 3ml and 130 ml is a huge diff...if the charge nurse wouldnt have caught her then the pt would have been dead...although i cant imagine trying to get a 130 cc out of those little insulin vials.....wouldnt it take like a ton of vials to even make 130 cc? it just seems like such an obvious mistake..maybe im missing something? confused... :uhoh21:

:redlight: oh my god, that is so scary!!! i am so afraid for that patient's life, not for that nurse. :sofahider yes. before a nurse is preparing

meds for the patient, they should always question in their mind about

why this med is given, if it is given for the right reason, and if dosage

is reasonable. if anyone of this doesnt seem like and send up a red

flag, check original doctor's order, and look up in the med book to see

what is the usual dosage of the medication that is suppose to be

given. believe me, doctors do make mistakes when they are writing

orders, and nurses make mistakes when transcribing orders. don't

just follow the orders... alaways question orders.. whew, i almost

had a heart attack while reading this thread.... :smackingf

maybe your mom should have a surgery at onother hospital...

begalli · Jun 25, 2005

If I ever get a dosage on an MAR that I question... and 130 ML of insulin would do that... I would go directly to the chart, verify, and then call the doctor to get a clarification. That is an obvious error!!!! And if the doctor continued to order this drug in this manner... I would refuse to give the med. First of all, you administer insulin in units, not ML. You use an insulin syringe to draw it up... which is marked in units, not ML.

Absolutely positively.

mommatrauma, RN · Jun 25, 2005

3 ml is even too much insulin...that would be equal to 300u of insulin...so maybe there really is more to the story that is missing...that even sent up a red flag...the 130 ml syringe..short of an irrigation set, ie ngt or foley irrigation set, I don't think you will find a syringe that is that large...vials are usually 10cc vials, so when you call pharmacy and request 13 bottle of insulin...I'm sure they would question it..The order was probably 130 units of insulin which would be a higher dose for most, but if the patient was very large or a very brittle diabetic, may have required a higher dose...Seeing also as the regular insulin syringes only hold 100u maybe she was looking for a syringe that was bigger so the patient did not have to get 2 shots...I find it extremely hard to believe in an seasoned RN did not question this order...I wrote the 130cc order out on paper for 4 of our brand new RNs and every single one of them said no way, its way to high...so even the new nurses picked up on it right away...

GrnHonu99, RN · Jun 25, 2005

First of all, you administer insulin in units, not ML. You use an insulin syringe to draw it up... which is marked in units, not ML.
DUH...lol i should have known that...i meant to say units...usually i have seen the insulin syringes and they are clearly marked with orange caps? i just kept thinking ive never seen a syringe that is 130 units...and the only insulin vials i have seen were pretty small...and seeing she was looking for a syringe...i would think it would take quite a few of those tiny vials to fill up 130 unit syringe...scary...im going to be so nervous when my mom has her surg. there in august... :uhoh21:

begalli · Jun 25, 2005

That would be a 13,000 unit dose of insulin!

It's just so incredibly hard to believe!!! :eek:

GrnHonu99, RN · Jun 25, 2005

3 ml is even too much insulin...that would be equal to 300u of insulin...so maybe there really is more to the story that is missing...that even sent up a red flag...the 130 ml syringe..short of an irrigation set, ie ngt or foley irrigation set, I don't think you will find a syringe that is that large...vials are usually 10cc vials, so when you call pharmacy and request 13 bottle of insulin...I'm sure they would question it..The order was probably 130 units of insulin which would be a higher dose for most, but if the patient was very large or a very brittle diabetic, may have required a higher dose...Seeing also as the regular insulin syringes only hold 100u maybe she was looking for a syringe that was bigger so the patient did not have to get 2 shots...I find it extremely hard to believe in an seasoned RN did not question this order...I wrote the 130cc order out on paper for 4 of our brand new RNs and every single one of them said no way, its way to high...so even the new nurses picked up on it right away...

well the charge nurse and my mom were discussing the situation as they were both present when it happened...and the scariest part i guess was that the nurses response was "its not my fault i didnt write it, why should i have to check it.." yikes...but the same response i had, was what the charge nurse called her out on, my mom said she heard her ask that so...i dunno...it just kinda blew me away...the charge nurse even went as far to ask this other nurse how long she had been working and when she graduated from ns...she also asked her if she even knew of a syringe that large...and then the charge nurse went on to say that the dose of insulin that she was going to administer would have KILLED the pt...i also know that the charge nurse was very upset that the other nurse didnt check the order...

i cant remember if my mom said the MAR said 130 ml or 130 units...cant remember, but i do know that the bottom line was, wether it was units or ml it was a dose that was waaaayyy off....130 units, would you ever give a pt that much? I know the insulin syringe we used in class was very small 100 units...and im pretty sure my prof said that you usually dont even admin 100 units of insulin usually...but like i said im a pretty new student so i may not know...