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:
The nurse is legally responsible for the dose he/she administers, regardless of what the doc writes. If it is not a "reasonable" dose & the nurse fails to question it (by either calling the doc and/or pharmacist, or by checking Rx website/book sources), that nurse is not providing safe practice.
The nurse you describe is endangering the patients by blindly following written orders. This should be reported to management and/or influencial nurses/physicians in the facility so that the travel nurse is pulled from the assignment.
I wonder if you got the story straight. Insulin is given in Units. Not ml. Even 100 units would only fill a 1ml syringe. Wonder if the agency nurse was impaired?
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:
Specializes in LTC, HOSPICE, HOME, PAIN MANAGEMENT, ETC.
originally posted by elkmnin06
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hi, i hope i do this correctly. i read this board a lot. i love it and have learned so much. however i'm not sure how to post a message.
i am so sorry about all the attacks you have received but as far as i'm concerned, i am glad you brought this up. many of the posters offered excellent feedback. i have been an rn for 30 years (!!!! :) it's hard to believe so much time has gone by.) and i still have another nurse doublecheck insulin. i will never have too much experience to take the precautions i learned 30 years ago and still practice today.
as far as the believability(?word?)of this incident, i have seen far too many situations equally unbelievable to question the veracity of what your mom said happened. as they say "truth is stranger than fiction"
at least you will be there to look after your mom and be her advocate! thank god this patient had a guardian angel ! i firmly believe all patients need an advocate. i have seen too much, both professionly and personally to think otherwise. i could tell you absolute nightmares from what i've experienced! the thing that matters is i'm still out there along with many others who care about the patients first and foremost. i continue to question dr's orders that don't seem right even at the risk of looking (dumb) and i continue to advocate for my patients.
don't stay away from the boards. they are invaluable for what they offer and you will have the opportunity to share your own experience, strength and hope as you grow. i hope to continue to be a part of this and hope i can get the self confidence to give back some of what i have received.
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...
THANKYOU FOR POINTING THAT OUT-3ML IS TOO MUCH INSULIN TO BE ADMIN NO MATTER WHAT TYPE OF INSULIN BEING GIVEN, INSULIN IS ALWAYS MEASURED IN UNITS AND WRITTEN IN UNITS, SOMETHING AINT RIGHT WITH THIS STORY
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.
Having two nurses check insulin dosages is NOT a new phenomenon. I have been a nurse for 20 years and we were always taught in school that two have to check insulin.
I think it is more worrisome that a nurse wouldn't question the amount of that insulin dose.
Specializes in oncology, surgical stepdown, ACLS & OCN.
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:
That much insulin would probably kill an elephant, Nurse should have checked the the dr;s order and the an incident report should have been written and sent to risk management.
jhowirn
36 Posts
And I got written up last month for running Diprivan at a slightly higher than normal rate........