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:
sigh....i dont know how many times i have to type this...geez...
NO ONE SAID ANYONE WAS REPORTING HER TO ANYONE!!!!!!!!! Who would report her? ME?? Um no...and niether would my mom...if she gets reported that is up to the CN, she is the one who found her, she is the one who had the conversation with her, so wether or not this nurse gets reported to ANYONE has NOTHING to do with ME or my mom for that matter!....I have no idea what her intentions are and will prob never find out...
also like I said before...whether or not YOU believe the situation is NOT THE POINT OF THE THREAD..so lets move on! Personally, I could care less who believes it or not.
I think that some you have taken this thread and turned it around the wrong way. I never once asked whether or not I should reprot her or if she should be turned in to the BON and Im sure some of you who were not there at all know the situation better than anyone else so lets please just move on.
And yes, if she did say ml in the med room im sure that she prob meant units..so LETS GET OVER THIS POINT AND MOVE ON. EITHER WAY SHE THOUGHT THE ORDER SAID 130 INSTEAD OF 13...wether or not she really thought it was ml or units either one would STILL have hurt the pt.
I will say this one more time and one more time ONLY...the point of this thread was NOT to discuss whether or not my mom or I should report this woman, that NEVER came into discussion. THis thread is also NOT to discuss whether or not my mom is the kind of person who would "gossip just to get someone into trouble". This thread is NOT to discuss wether or not YOU BELIEVE if this is true.
If you would like to post something about a med error w/insulin please do so. I probably wont be revisiting this thread as we cant seem to discuss anything except my mothers and my integrity. THAT WAS ABSOLUTELY NOT THE POINT OF THIS THREAD.
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.)
im not sure, my mom said but I dont remember....whatever it was it was supposed to be 13 units and was either taken off completely wrong by the previous n urse (as her facility does not allow anyone but the nurses to take off the order) or was written in that it looked like 130 with no measurements afterward. If you really want to know, I will ask and you can PM me.
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:
This agency nurse is dangerous. Any first year nursing student would probably know that 130ml of something is way too much! See, you are a student and you know already!
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
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.
You said exactly what I am thinking. Be REALLY careful with hearsay, even if it's from your mom. And be careful what you post on any internet board.
So scary. I would like to see if the order was written 13.0units or 13u which the u can look like a zero -- this is why these documentations are no-nos. If that was the case, I would like see the hospital authorities to reprimand the prescriber as (s)he should bear some of the consequences of this potential error JUST TO REINFORCE THAT THIS DOCUMENTATION IS NOT ALLOWED. It might save another patient's life in the future.
Was the nurse going to have another nurse check her insulin dose? And how big are the insulin bottles anyway? Anytime you would have to use 2 or more bottles of med, chances are you screwed up. If you are giving more than 1cc subcutaneous, double check it. More than 3-5 cc IM, double check it (with another nurse, your math, with Mosby's, call the Pharacist, etc).
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Thank GOD she did not kill anyone (this time). This would qualify as a near miss though (sentinal event). Does this type of thing get reported to the BON? A nurse who is this dangerous should not be able to practice. Would you want her to take care of you, your mother, your child, your grandfather?
Specializes in Telemetry, ICU, Resource Pool, Dialysis.
ELKMNin06 - You're right, I think things have been blown a bit out of proportion here. And whoever said it's safer to swim with jaws than to work in some institutions was absolutely right. There seem to be alot of folks jumping to conclusions here without applying any logic to the situation at all. I seriously doubt if there has EVER been a situation where someone has given or tried to give 130mls of insulin subq as people have decided this nurse almost did. It defies logic on every level imaginable.
So, the moral of this story is..... the practice of using u for the word "units" is dangerous. The nurse in question almost gave 130 units of insulin because either she, or the nurse who transcribed the order, mistook the u for a 0. Always double check larger than normal insulin orders. Never use u for units. Double check an order written using u for units. Lesson learned.
I have seen more med mistakes than I ever thought possible. Nurses cover for other nurses and so do the doc's. I'm getting the message that it is alright to make mistakes if you do do it politely. Didn't anyone else ever get this impression. I have not finished nursing school yet (2 semesters to go). I'm getting really frightened by the lies I have heard and those who tell them.
The fact that this nurse did not ? that order from the start is the scary part!!! I am a ER nurse and when we have t give insulin we must have it double checked by another RN before giving it. Also fill do the occasional agency shift ( it pays awsome) and you are going in blind but even a nurse on her first day out of school should be able to recognize that 130u of insulin is way off!!
I WAS RESPONDING TO THE STORY YOU POSTED ABOUT THE INSULIN. AT MY HOSPITAL, DUE TO THE FACT THAT A NURSE, I THINK SHE WAS A NEW GRAD, ADMINISTERED 150 UNITS OF INSULIN ULTIMATELY KILLING THE PATIENT, TWO NURSES HAVE TO CHECK THE MAR, THE INSULIN VIAL AND THE DOSAGE DRAWN UP IN THE SYRINGE. THIS IS A GOOD THING TO GET IN THE HABIT OF DOING, BECAUSE SOME OF THE AGENCY NURSES THAT WE USE TELL US THAT THIS IS BECOMING COMMON PRACTICE IN A LOT OF THE HOSPITALS AROUND. IT IS ALSO GOOD PRACTICE TO HAVE ANOTHER NURSE CHECK THE DOSAGE OF OTHER MEDICATIONS THAT YOU DRAW UP SUCH AS THINGS LIKE DIG, DILANTIN, LOPRESSOR, CARDIZEM AND THE SUCH. IT IS ALWAYS GOOD TO HAVE SOME ONE DOUBLE CHECK JUST FOR PATIENT SAFTEY. IT MIGHT MAKE YOU FEEL STUPID BUT IN THE LONG RUN YOUR PATIENTS WILL NOT BE HARMED BECAUSE YOU MADE A MISTAKE. ALSO IN MY EXPERIENCE, YOU HAVE TO USE COMMON SENSE. IF IT SEEMS LIKE TOO MUCH IT PROBABLY IS. USE YOUR INSTICTS.
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:
I have a resident that gets 130 units of lantus q hs. Takes two syringes.
GrnHonu99, RN
1,459 Posts
sigh....i dont know how many times i have to type this...geez...
NO ONE SAID ANYONE WAS REPORTING HER TO ANYONE!!!!!!!!! Who would report her? ME?? Um no...and niether would my mom...if she gets reported that is up to the CN, she is the one who found her, she is the one who had the conversation with her, so wether or not this nurse gets reported to ANYONE has NOTHING to do with ME or my mom for that matter!....I have no idea what her intentions are and will prob never find out...
also like I said before...whether or not YOU believe the situation is NOT THE POINT OF THE THREAD..so lets move on! Personally, I could care less who believes it or not.
I think that some you have taken this thread and turned it around the wrong way. I never once asked whether or not I should reprot her or if she should be turned in to the BON and Im sure some of you who were not there at all know the situation better than anyone else so lets please just move on.
And yes, if she did say ml in the med room im sure that she prob meant units..so LETS GET OVER THIS POINT AND MOVE ON. EITHER WAY SHE THOUGHT THE ORDER SAID 130 INSTEAD OF 13...wether or not she really thought it was ml or units either one would STILL have hurt the pt.
I will say this one more time and one more time ONLY...the point of this thread was NOT to discuss whether or not my mom or I should report this woman, that NEVER came into discussion. THis thread is also NOT to discuss whether or not my mom is the kind of person who would "gossip just to get someone into trouble". This thread is NOT to discuss wether or not YOU BELIEVE if this is true.
If you would like to post something about a med error w/insulin please do so. I probably wont be revisiting this thread as we cant seem to discuss anything except my mothers and my integrity. THAT WAS ABSOLUTELY NOT THE POINT OF THIS THREAD.