med error:

[jenac]

I found a med error the other night-order was for Humalog 75/25 insulin. When I rolled it- it stayed clear. In school- we were taught (and grilled) on the apppearence of insulin. I knew it should be cloudy-so I refused to give it, called a second nurse to verify it, and the pharmacy for verification. It should have been cloudy. So I borrowed the correct insulin from another resident-and pulled the old vial. Turns out the pharmacy had mislabed a vial of Humalog.

I kept hearing from the two nurses who had actually given the incorrect insulin- "It's the pharmacy's error for mislabeling it." How about the personal liability of those who gave it? The DON gave the error to the pharmacy. I thought we were liabel as the ones who utlimately gave it. Any opinions?

[CougRN]

it varies from state to state. percentage of blame is regulated by state organizations. some states place 100% on nurses or 100% on pharmacy. it can also be divided up on both. yes, i can see how it was an error on the nurses part but ultimate blame will fall on the pharmacy for mislabeling the drug.

[Katnip, RN]

Actually, it often falls the other way around. Ultimately, the person administering the med is required to be verifying the right drug. That's why nurses take pharmacology. That's why so many facilities require a double checking of insulin with another nurse before administration.

Giving the wrong type on insulin is just too obvious an error.

[jnette, ASN, EMT-I]

Good catch, good job !

Surprising that the other two nurses didn't notice... wierd.

[flashpoint]

Great catch...that's why it's important to learn what drugs look like in addition to all fo the basic pharmacology! Insulin is one that should have been caught right away...

What you you all think when pharmacy mislabels a tablet or liquid...something that you honestly can't tell what it is by looking? We recently had a pharmacy tech dispense dilantin instead of phenobarbital...she simply grabbed the wrong bottle and since neither comes in unit dose in our facility, the nurse didn't notice. Then generic dilatin is a plain while capsule...no tell tale red stripe... No one caught it until the next day, when the same nurse had the appropriate phenobarb tablet in her med drawer. Who should take the blame then? Same pharmcy tech also gave phenobarb elixir instead of phenergan with codeine...she got fired after that one.

[Sharon]

Excellent catch and great job.

In the specific situations previously listed in this thread, I think placing blame on an individual is another example of healthcare provider's sense of martyrdom. Even though I am a former nursing instructor and taught my students that they should know visually the top 100 drugs given on their unit and during a code. It is physiologically impractical to know all drugs by their appearance now.

Current best practices in risk management place the blame on a system's failure not an individual's. The amount of knowledge we have to have at our fingertips is so vast that many aspects should have been automated decades ago.

Within a few years all medication will be bar-coded to prevent such miss-steps(including indivdual pills). Please reassure the other staff that they were neither bad people nor providers.

[Agnus]

This was clearly a system error. You caught it.

For fun, let's just say this went to court.

I beleive there would be an attempt to hold not only pharmacy liable but also the nurse.

The nurse is the final check to insure medication is correct.

As the plantif's attorney I would ask you. I would ask if you kow the differenct between the two insulins. I would ask what does regular look like and what does a delayed releanse look like. I would ask if you checked the clairity of the insulin.

Because you did not check the clairty you would be held at least in part responsible. As a nurse it is fair to assume you can recognize that a clear insulin is not a mixture of regular and a slower released insulin.

Blaming should not be done here. It was a system error and the system needs fixing. I do not understand why pharmacy is placing lables on insulin. They arrive from the manufacture with lables. It is distributed by pharmacy in the original container. I am puzzeled.

Is this a case were pharmacy combined 2 insulins? If so WHY. Is it cheaper? If it is cheaper is the savings worth the risk?

I have never seen a situation where pharmacy mixed insullins.

[Sharon]

I have participated in pre-trial work as an expert witness and it rarely gets dumped on the nurse. I can't remember a specific case in the US in the past 20 years where the situation as described above resulted in the nurse being the single one to be held liable. What I have seen is the plaintiff's attorney has blamed the system i.e. the healthcare business for failure to institute system safe guards that have existed in other industry for decades.

Requiring a nurse to know what every medication looks like is like:

Requiring:

An airline pilot to notice the difference in size by mm of a part change on a plane before takeoff.

A teacher to know all of the cultural facts of the students they could possible teach in a given school district (ours has 123 plus regional variants). I have cleaning up the adverse health effects of quite a few of these cases this week.

A race car driver to know the potential landing location of car part (s) based on the mathematical equations of an incident triggering ejection of a part.

A film crew to know what content to not include to avoid children from attempting to repeat the content and injuring and killing themselves.

There are many examples in many other professions where the content is so vast and the potential risk of injury or death exists yet the standards to know the information on sight is not expected or required. Requiring health care workers to do the impossible is institutionalized martyrdom.

[tonchitoRN]

just recently there was an np article posted on allnurses.com about two correctional nurses who were sued. it turns out the pharmacy dispensed and mislabeled a drug. the order was for a bp med and the pharmacy sent a chemo drug. two inmates died due to this error.

i do remember part of their defense was that it is virtually impossible to look up every pill in the pdr to see if it resembled the pix.

maybe someone with a little time can post the url for this article. i wish i remember the details.

[purplemania, BSN, RN]

Every nurse is accountable and responsible for what they do. I woul dnot want to test the theory of "it was the pharmacy's fault" in court.

You did GREAT by applying your knowledge to best care for your patient.

[cannoli]

Insulin, cloudy versus clear, is obvious, but many instances are not.

In many instances, there is no way one would know if a med was mislabeled, so many look alike, and what about the differences between brand names and generics?

One drug may come in many different colors, tablet shape, etc, depending on what company manufactured it.

Some times there is just no way to know that something is mislabeled.

Doesn't insulin come with a manufactures label on it? Why was the pharmacy relabeling insulin?

[susanmary]

Doesn't insulin come with a manufactures label on it? Why was the pharmacy relabeling insulin? [/b]

My thoughts exactly. Please don't tell me that your facility MIXES their own 75/25 -- say it isn't so!