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:
Was she really saying ML and not asking for units? I just can't find that believable... I guess it is beyond me. Don't be offended by this question, but is your mom a nurse? Why I am asking is I was wondering if she is maybe mixed up as to what the nurse was wanting or saying, etc... I'm not saying that as a dig (honest). I just find it sooo unbelievable, I have to wonder if there was some big mix up. Of course, then other staff gets wind of what happened... and then it gets all mixed up and blown out of the water. Just wondered!!
Yes she is, and she was told by the charge nurse that saw it happen first hand. The CN, told her later what happened after my mom witnessed the charge nurse confronting the agency nurse about this OBSCENE mistake. I dont know why this woman said what she did, in fact that is why i started this thread. Maybe she just accidentaly said ml and really meant units, who knows..either way she definetly absolutely thought it was 130 instead of 13 so whether she meant 130 units or 130 ml, it would have hurt maybe even killed the pt either way. She definetly said ml in the med room, but I hope hope hope that she just accidentaly said that and that she really knew that insulin was measured in units...my original thought was that 130 units or ml was waaayyy to much insulin to give anyone and no matter if she really thought it said units or ml, shouldnt the number 130 automatically send up a red flag...even if it was 130 units and written clearly most ppl dont get that much so if it were me, even if it were right, id want to check it?
Im not sure I understand what you mean by the situation getting "blown out of proportion". I have no idea what the outcome of the situation was..i dont work at that facility but I don't think that the "other staff got wind of it", i'm pretty sure it was just the charge nurse and my mom...now my mom told me but I dont work there. LIke I said before I dont know what the outcome of the situation was. I don't think anyone was spreading it around and talking about her or whatnot if that is what you meant...it is really up to the charge nurse what road she wants to pursue...
BUT...the bottom line is, no matter what she was doing, or thinking or whatever...she was about to make a critical med error...no matter wether she really meant to give 130 ml or 130 units either way it would have seriously seriously hurt the pt. and then on top of that her attitude was that it wasnt her fault bc she wasnt the one who took off the order...now my mom is due to have a total hip replacement at that hospital and she will be on that floor....hard for her bc she works there but harder bc she is worried about the quality of care she will receive there...unfort. the MD that is performing her surg. only does surgeries at that part. hospital.
Per JCAHO protocol, insulin should always be double checked by two licensed nurses before administration. And this is hospital policy at every facility that I have ever worked at.
Just another reason for having this rule in place.
OK, so your mom didn't actually witness this; she was told this by the charge nurse, and now you're relating it. So what we have is a third-hand account of something that may or may not have happened the way it was described.
Sorry, no offense to the OP or her mother, but I'm having a hard time believing this. Yes, there are some bad nurses out there, but there are just as many (if not more) people who gossip and say things just to set someone else up for trouble. Whenever I hear a story that sounds too incredible to be true, I try to give the person being discussed (in this case, the agency nurse) the benefit of the doubt. We've had many a thread that's started out "There was this nurse who did...(insert incredible story)" that then becomes, "Well, I wasn't actually there, but someone told me that someone saw this happen."
And agency nurses are prime targets for this kind of stuff; I've seen it on more than one occasion.
OK, so your mom didn't actually witness this; she was told this by the charge nurse, and now you're relating it. So what we have is a third-hand account of something that may or may not have happened the way it was described.
Sorry, no offense to the OP or her mother, but I'm having a hard time believing this. Yes, there are some bad nurses out there, but there are just as many (if not more) people who gossip and say things just to set someone else up for trouble. Whenever I hear a story that sounds too incredible to be true, I try to give the person being discussed (in this case, the agency nurse) the benefit of the doubt. We've had many a thread that's started out "There was this nurse who did...(insert incredible story)" that then becomes, "Well, I wasn't actually there, but someone told me that someone saw this happen."
And agency nurses are prime targets for this kind of stuff; I've seen it on more than one occasion.
believe what you want. My mother is not a gossip and I am not going to get into that. This is a public board which is anonymous so I do not consider this "gossiping". My mom told ME and like I said before she wasn't talking to anyone else about it...besides that really isn't the point of the thread. Also like I said in my earlier posts was that I dont know the outcome of this situation and niether does my mom. Secondly, what my mom DID witness was the CN and the agency nurse discussing the situation right after it happened...she stood there while the agency nurse said and I quote "its not my fault I didnt take the order off"....ANYONE who would make a statement like that after making a critical med error does not deserve the benefit of the doubt. AND YES, my mother heard that FIRST HAND.
The nurse absolutely made a med error or was about to, there is no question in that. She stood there and acknowledged it right in front of the charge nurse and my mother. I also do take offense that you infer that either my mother or the charge nurse would "gossip" or "say things just to set someone else up for trouble". Not that I need to explain but again, like I said before, the incident came up bc my mom will be having surgery on this same floor and this particular facility issues...
As I said before, this is a discussion board, if you would like to comment on a med error please do so, if you wish to question the situation thats not the point of this thread.
In fact, I am tired of defending my mother and my post. I was hoping to discuss med errors but since the only thing we can seem to discuss is whether or not my mother is a gossip and/or misconstrued the situation, I see that continuing this thread is pointless. I will think next time before I start another thread. :uhoh21:
OK, so your mom didn't actually witness this; she was told this by the charge nurse, and now you're relating it. So what we have is a third-hand account of something that may or may not have happened the way it was described.
Sorry, no offense to the OP or her mother, but I'm having a hard time believing this. Yes, there are some bad nurses out there, but there are just as many (if not more) people who gossip and say things just to set someone else up for trouble. Whenever I hear a story that sounds too incredible to be true, I try to give the person being discussed (in this case, the agency nurse) the benefit of the doubt. We've had many a thread that's started out "There was this nurse who did...(insert incredible story)" that then becomes, "Well, I wasn't actually there, but someone told me that someone saw this happen."
And agency nurses are prime targets for this kind of stuff; I've seen it on more than one occasion.
I have worked on enough units to know how nurses gossip. I do find it rather incredible that a nurse with that many years of experience has never given insulin. I don't think the fault is not with your mother, she is relaying what she was told by the charge nurse. I do wonder if the charge nurse understood what was being said, perhaps she was looking for an insulin syringe capable of holding 130 units not 130 ml and the charge nurse did not hear her correctly. Still should have due dilligence to proper administration of dose - know how to administer the dose, checking the correct dosage for pt weight etc.. I do know with so many patients that it is difficult (impossible) to check every med, however; I do check any new med order before I adminster it.
believe what you want. my mother is not a gossip and i am not going to get into that. this is a public board which is anonymous so i do not consider this "gossiping". my mom told me and like i said before she wasn't talking to anyone else about it...besides that really isn't the point of the thread. also like i said in my earlier posts was that i dont know the outcome of this situation and niether does my mom. secondly, what my mom did witness was the cn and the agency nurse discussing the situation right after it happened...she stood there while the agency nurse said and i quote "its not my fault i didnt take the order off"....anyone who would make a statement like that after making a critical med error does not deserve the benefit of the doubt. and yes, my mother heard that first hand.
the nurse absolutely made a med error or was about to, there is no question in that. she stood there and acknowledged it right in front of the charge nurse and my mother. i also do take offense that you infer that either my mother or the charge nurse would "gossip" or "say things just to set someone else up for trouble". not that i need to explain but again, like i said before, the incident came up bc my mom will be having surgery on this same floor and this particular facility issues...
as i said before, this is a discussion board, if you would like to comment on a med error please do so, if you wish to question the situation thats not the point of this thread.
in fact, i am tired of defending my mother and my post. i was hoping to discuss med errors but since the only thing we can seem to discuss is whether or not my mother is a gossip and/or misconstrued the situation, i see that continuing this thread is pointless. i will think next time before i start another thread. :uhoh21:
i think why we are asking is because this seems sooo unbelievable... i mean, they drill that stuff into your head in nursing school, and if you've practiced for more than a few months you'll have came into contact with insulin. it is important to always give the benefit of the doubt, and not "jump" the person. especially if we didn't hear it first hand... and when the person isn't here to defend herself.
ok... i just want to point out two things. you might get mad at me, but i think that they are important. at least, they are to me.
this board isn't anonymous. if you do searches, there are people who have been noticed by fellow nurses at work and their posts printed off and hung in breakrooms. people have been disciplined because of their comments here. it is not anonymous. this nurse that you don't know but are talking about could be reading this thread as we speak!!! i would be very, very careful.
second... ok, this where i will make you mad. and in part, i am sorry, as i don't like to start conflict... but i think it is something we should always think about. i would be sooo embarrassed if i knew that i made a mistake and everyone was going home and talking about it to their families. not to mention that's not really professional...
i mean, what business is it of my daughters to know what happened at my work to my coworker... and of a situation that i caught the tail end of and got the rest of the story second hand? should i come home and tell my husband about some huge med error my coworker made, and is it any of his business? nurse or not?
i feel sorry for agency nurses. they are always targets of this kind of stuff. i am thinking that your mom was just trying to tell you to keep your eyes open for that sort of thing... meds errors and such. but, just always think that when you're at work, at clinical, etc, that it is important to act professionally and keep work / personel issues at work (it is hard) and to try not to gossip about your coworkers (very hard... especially if you are on a small unit). and that is hard... i am sure that 99.9% of us have all accidentally fell into situations where we aren't doing that. but we should at least effort to do it. confidentiality isn't only for patients... its for your coworkers too.
i don't think you were being malicious in starting this thread, or trying to cause problems. i would just be very, very careful!
And, while this may sound harsh too, someone who is only just starting nursing school really is not in a position to be passing judgement on the practice of a nurse who has been working for years. This isn't just the OP; there's another thread where a student is relating serious allegations about a nurse in a hospital, and those allegations have not even been substantiated.
People on this thread were talking about sanctions, calling the BON, etc. That frightens me, that those suggestions would be made when there is no first hand eyewitness account of the incident. Even if I had seen it for myself, I think there are other steps to take before calling the BON.
We all misspeak at times at work, especially if it gets busy. And I have seen other nurses take what may have been a minor situation and blow it way out of proportion. Who knows what the charge nurse said to this nurse? Maybe the nurse got defensive and blurted out her response...not that it was right, but who here hasn't said something in haste?
It's good to ask questions as a student. But remember, you are still learning; actually, you've just started. There are going to be many situations that may not seem to make sense at the time that will make sense later when you've graduated and are working.
No one is attacking you or your mother. I think what others are trying to say is, not to be too quick to take as gospel something you haven't seen for yourself. Peoples' careers have been hurt by that. I wouldn't want it on my conscience that I hurt someone over talk that was later found to be exagerrated/a misunderstanding.
This board is far from anonymous. A while back, someone was disciplined at work over something she posted here; even though she'd changed some of the details, someone else put it together and printed it out and posted it at her job on a bulletin board. So no, this is not just an anonymous place where details can be discussed; if you do, you do so at your own peril.
believe what you want. My mother is not a gossip and I am not going to get into that. This is a public board which is anonymous so I do not consider this "gossiping". My mom told ME and like I said before she wasn't talking to anyone else about it...besides that really isn't the point of the thread. Also like I said in my earlier posts was that I dont know the outcome of this situation and niether does my mom. Secondly, what my mom DID witness was the CN and the agency nurse discussing the situation right after it happened...she stood there while the agency nurse said and I quote "its not my fault I didnt take the order off"....ANYONE who would make a statement like that after making a critical med error does not deserve the benefit of the doubt. AND YES, my mother heard that FIRST HAND.
The nurse absolutely made a med error or was about to, there is no question in that. She stood there and acknowledged it right in front of the charge nurse and my mother. I also do take offense that you infer that either my mother or the charge nurse would "gossip" or "say things just to set someone else up for trouble". Not that I need to explain but again, like I said before, the incident came up bc my mom will be having surgery on this same floor and this particular facility issues...
As I said before, this is a discussion board, if you would like to comment on a med error please do so, if you wish to question the situation thats not the point of this thread.
In fact, I am tired of defending my mother and my post. I was hoping to discuss med errors but since the only thing we can seem to discuss is whether or not my mother is a gossip and/or misconstrued the situation, I see that continuing this thread is pointless. I will think next time before I start another thread. :uhoh21:
I don't think that anyone meant to question the integrity of your mother, her coworkers or the story you post. I'm sorry you took it that way....I think what we are hoping that as professionals, and as seasoned nurses as is the one in this situation, that there is more to the story that we are missing...We are hoping that somewhere along the line there was more common sense, and maybe just a simple misunderstanding of how things were said or done. I'm sorry you feel as though you have to defend your post or your mother...I understand her concerns as she will be a patient on that same floor...It is scary, but the good thing for your mom is she knows more than the average patient, she is ahead of the game...plus she'll have you looking out for her if she's not in the right state of mind post-op to know what is going on. I think regardless of how this story happened, didn't happen, or what was said or not said, we can learn a few very valuable lessons from it. We are never to experienced to be cautious, we can learn from each others mistakes, we can be more vigilant of possible transcription errors, and we can all make sure we are patient advocates, whether they are strangers or someone close to us. Please don't be so defensive, I know its close to your heart because it involves your mom, but sometimes when people think out loud, it sounds harsher typed than it would if you were just throwing it around in conversation.
My first thought when I read this was why would an insulin order be written up in "ml". You never use a ml marked syringe-- only units. Three mls would be a huge dose.
I cannot believe a seasoned nurse would look for a 130 ml syringe for insulin. I cannot even believe a student nurse with a few semesters worth of clinicals under her belt would do such a thing.
I tend to give my colleagues the benefit of the doubt. We all make stupid mistakes sometimes, but this one is ridiculous!
She could have been harried and said 130 ml when she in her mind meant units. Sometimes the wrong thing comes out of someones mouth. Then someone hears it and repeats and then a legend is born, when the original nurse saying it had no intention of giving 130 ml and was thinking units the whole time.
I still stay 130 units should have been a red flag for her to double check the original order.
But this is ridiculous; there were people advocating for the nurse's license to be revoked/restricted, or suggesting that the BON be called. And people wonder why nurses get fed up or burned out; good grief, it's safer to go swimming with JAWS than work in some facilities.
I still say the bottom line is if you didn't see it with your own eyes or hear it with your own ears, then don't feed the rumor mill. Even if you do see/hear something that sounds "off," get clarification first before assuming the worst of someone.
130 units is a lot but not unheard of, I've given 120 of NPH though I checked and checked and checked, then asked the patient who confirmed she did take that large a dose, then I asked her how she did it as our largest insulin syringes only go to 100 units and she confirmed she always gave herself two injections, one of 100 units and one of 20 units, so I was reassured and gave it (and she did fine). She was a very insulin resistant large lady.
Thank you for stating this. Nobody questioned whether this was regular or long acting insulin. Usually, long acting dosages are much larger than regular insulin. (Although it is true that 130 units of NPH would be out of the ordinary it is certainly not the same as giving 130 units of regular insulin.)
GrnHonu99, RN
1,459 Posts
Yes she is, and she was told by the charge nurse that saw it happen first hand. The CN, told her later what happened after my mom witnessed the charge nurse confronting the agency nurse about this OBSCENE mistake. I dont know why this woman said what she did, in fact that is why i started this thread. Maybe she just accidentaly said ml and really meant units, who knows..either way she definetly absolutely thought it was 130 instead of 13 so whether she meant 130 units or 130 ml, it would have hurt maybe even killed the pt either way. She definetly said ml in the med room, but I hope hope hope that she just accidentaly said that and that she really knew that insulin was measured in units...my original thought was that 130 units or ml was waaayyy to much insulin to give anyone and no matter if she really thought it said units or ml, shouldnt the number 130 automatically send up a red flag...even if it was 130 units and written clearly most ppl dont get that much so if it were me, even if it were right, id want to check it?
Im not sure I understand what you mean by the situation getting "blown out of proportion". I have no idea what the outcome of the situation was..i dont work at that facility but I don't think that the "other staff got wind of it", i'm pretty sure it was just the charge nurse and my mom...now my mom told me but I dont work there. LIke I said before I dont know what the outcome of the situation was. I don't think anyone was spreading it around and talking about her or whatnot if that is what you meant...it is really up to the charge nurse what road she wants to pursue...
BUT...the bottom line is, no matter what she was doing, or thinking or whatever...she was about to make a critical med error...no matter wether she really meant to give 130 ml or 130 units either way it would have seriously seriously hurt the pt. and then on top of that her attitude was that it wasnt her fault bc she wasnt the one who took off the order...now my mom is due to have a total hip replacement at that hospital and she will be on that floor....hard for her bc she works there but harder bc she is worried about the quality of care she will receive there...unfort. the MD that is performing her surg. only does surgeries at that part. hospital.