Med Error

[Rada]

I got an order to give insulin IV. Dextrose and calcium Gluconate due to a critical K . This order was so odd to me. I never heard anything like it. 

I asked the charge and I said insulin and dextrose are  apposite is this order correct? She said yes, they will balance each other. It was my first time giving IV insulin.

Order said 9 units and I gave 9 ml. It made sense to me at that time since it was IV and not subcutaneous, also it was unit per Kg. We never give insulin per kg.

After I administer the medication and press the accept bottom, I then double sign off popped off . I got the charge and said that I gave the medication. She said, "OK, so you gave 9 units?" At that moment, I realized that I gave 9 ml instead of 9 units.

I reported the error to Dr. and she sent the patient to ICU for close observation. Luckily, the patient survived but the Director insulted me, yelled at me, and told me to report myself to board of nursing. Also, he canceled my contact with that hospital. I am very traumatized and I want to quit nursing for ever. I'm just wondering if this decision is right or not? 

[kp2016]

My gosh. I am sorry. That really is a big mistake and I know you must be feeling devastated. 

I know for me sitting in my living room fully resting sipping my coffee with my feet up it is easy to think how could any nurse make the mistake of giving Insulin in units instead if mls…. And that is exactly the kind of judgmental and unhelpful attitude that is driving nurses away from the bedside. 

You made a serious mistake, you recognized it in time to correct the mistake and immediately reported yourself to get help for the patient. 

Please do not quit nursing! Anyone can make a mistake, it does not mean you need to give up! In future when doing something for the first time or if giving medications that you aren’t familiar with, ask someone to double check it with you. I know everyone is busy but honestly the fact that we are all “so busy” we have no time to double check each other is a sign of how broken and in need of urgent repair our health care system is. 

I have no thoughts on if you should report yourself to your BON or not. I’m leaning towards probably not. Let them report you and deal with that honestly if and when the BON contacts you. 

Best of luck!

[JKL33]

I am sorry this happened. I'm sure you feel terrible.

What are your basic circumstances, such as how much nursing experience do you have, how did you come to receive a contract at this hospital, do you have experience in an acute care job where you received proper orientation?

This error does sound like it involves fundamental lack of knowledge and at least some disregard of safety measures.

Leaving nursing is not really a solution unless it is what you want. But seeking out more appropriate job circumstances could be in order, as well as additional training/orientation/oversight.

It is to your credit that you quickly reported this so that the patient could be kept safe. You didn't mean to hurt anyone and you did the right thing as soon as you recognized the potential harm.

[Rada]

I have 5 years of nursing experience. 1.5 years in rehab and 3.5 years In med surge . This was a 13 weeks PRN assignment, similar to traveling but the difference is that you get hire through the hospital not agency . 

[Davey Do]

I chime in with the others in relaying that an error was made and you owned it and did something about it, Rada. To err is human, but to own it, act prudently, and forgive yourself are the earmarks of a quality nurse.

"I'm afraid I'll lose my license" or "I'm afraid I'll be reported to the BON" are two of the Big Bogeymen of the nursing profession.

Although I'm sure there are nurses who have lost their licenses, I do not personally know of one who did in my 40+ years in the field. And I know of some nurses who did some heinously illegal acts.

The BON typically acts on matters that tend to be malicious and/or grossly incompetent.

If every nurse that I worked with at Wrongway Regional Medical Center who made similar mistakes as you did, Rada, there would be only a hand full that were not terminated, reported to the board, or had their licenses pulled.

Off the top of my head, there were two nurses who made significant insulin errors without any major ramifications against them.

Another situation comes to mind that did not involve insulin, but a radiologist's report saying something along the lines of "comminuted fx of the R femur, suggesting need of ORIF" on a geriatric psych patient.

The off going nurse giving me a shift report, who was more focused on smoking than she was on the patient, handed me a faxed copy of the report stating, "I got this a couple of hours ago and didn't know what to do with it".

That nurse was not allowed to have a cigarette until all involved individuals were notified, all necessary charting was completed, and that patient was on their way to surgery.

Aside from me writing her up and my actions causing her to cry, she suffered no other negative ramifications of her grossly negligent actions.

Good luck and the best to you, Rada.

 

[londonflo]

11 hours ago, Rada said:

Order said 9 units and I gave 9 ml

You gave 900 units versus 9.  For the future, always use an 'insulin' syringe with any insulin order. Study the syringe for a start..  I do think you should look for a Continuing Education program (paper or in person) to understand why insulin is used to 'drive' potassium into the cell. Be proactive on learning..

I do feel for you. You did realize your mistake and communicated it appropriately and ensured the patient's welfare. 

[londonflo]

On 1/15/2022 at 7:54 AM, JKL33 said:

This error does sound like it involves fundamental lack of knowledge and at least some disregard of safety measures.

On 1/15/2022 at 7:44 AM, kp2016 said:

You made a serious mistake, you recognized it in time to correct the mistake

No the OP did not recognize it in time to correct the mistake. The patient went to ICU for further monitoring, not a reversal or correction of the mistake. 

As I recommended above the OP would be more safe in the future by     

1) attending a skills lab at a local college or hospital education department on the use of an insulin syringe versus a ml syringe, 

2) completing an educational program on insulin and potassium and a further program on electrolytes

3) an educational review for further 'travel' assignments. 

The patient got 900 units versus 9 units that were ordered. 

I feel for the RN (I truly do)  but there were many safety steps ignored a long the way. Please always ask for guidance on orders unfamiliar to you as an RN and ask your senior nurse to accompany you. . And please always ask questions. 

On 1/15/2022 at 1:08 AM, Rada said:

I asked the charge and I said insulin and dextrose are  apposite is this order correct? She said yes , they will balance each other. It was my first time giving IV insulin

Not enough questions asked. 

[kp2016]

On 1/15/2022 at 12:00 PM, londonflo said:

No the OP did not recognize it in time to correct the mistake. The patient went to ICU for further monitoring, not a reversal or correction of the mistake. 

As I recommended above the OP would be more safe in the future by   

1) attending a skills lab at a local college or hospital education department on the use of an insulin syringe versus a ml syringe, 

2) completing an educational program on insulin and potassium and a further program on electrolytes

3) an educational review for further 'travel' assignments. 

The patient got 900 units versus 9 units that were ordered. 

I feel for the RN but there were many safety steps ignored a long the way. Please always ask for guidance on orders unfamiliar to you as an RN and ask your senior nurse to accompany you. . And please always ask questions. 

Not enough questions asked. 

I respectfully disagree. The OP made a big mistake, they already know that and feel terrible, I’m assuming that is the actual point of their post.
Yes additional learning is appropriate, it’s appropriate for all of us all the time but suggesting what amounts to punitive extra education is not. 

[londonflo]

38 minutes ago, kp2016 said:

Yes additional learning is appropriate, it’s appropriate for all of us all the time but suggesting what amounts to punitive extra education is not. 

This is not punitive extra education. The RN did not have the education to recall and act on. I am not saying the OP is not knowledgeable in nursing practice. Rather I am meaning the the relationship to insulin and K.   It is basic education, more importantly along with reviewing the difference between an Insulin syringe to a 5 ml to 10 ml or higher ml syringe. The OP had to use a 10 ml syringe to draw up the insulin. Have you ever tried to draw up 9 ml from an insulin bottle (without putting in replacement air? 

Quote

also it was unit per Kg , we never give insulin per kg .

 Questioning the "units per Kg" wasn't investigated. These are the stumbling blocks for the education of the OP.   I do feel terrible for the OP but seek to improve her/his education and give an outlet to resolve their educational needs. The OP will be a better RN with additional learning on administering insulin IV.. Let's give positive actions to move forward rather than sympathy/empathy. 

To the OP, you will survive this...just give demonstrative evidence to your self and your employer that you have increased your knowledge in this area. That is advice to all who make mistakes with a limited knowledge base, Freely seek out who to improve what you need to know, That shows effort, insight and a willingness to improve.

Best wishes OP (I have been on several hospital units were insulin was ordered to decrease a K level.) In fact I did not know it until the first time I saw the insulin IV order for a patient with a high K.  I have explained the process to several RNs and SNs. It is complex...you are not alone in not knowing this. Just ask before you act on it. (Your drug handbook has a special section that explains this treatment....if you don't have a Davis drug handbook buy a used on (less than 5 years old) on eBay or Amazon. )

 

[Lunah, MSN, RN]

I worked with an amazing, very experienced nurse who gave too much insulin to a patient, it was a mixture of human factors + chance. In our syringe cabinet, the insulin syringes were next to the TB syringes, and she grabbed the TB syringe instead of the insulin syringe. She went to give 6 units of insulin IV and ended up giving 0.6 mL of insulin (60 units). She even held it up for another nurse to look at, who just saw the "6" on the ".6" line (those TB syringes don't have leading zeros, which I think is an issue in itself). The nurse was just devastated, but the patient was fine after a little extra time/monitoring and a meal in the ER, and we moved the insulin and TB syringes to opposite sides of the cabinet. Lesson learned for all of us. OP, I recommend clarifying orders that are unfamiliar, especially when giving a drug via an unfamiliar route or when you're not sure why you are even giving it. Glad to hear the patient was okay.

[londonflo]

5 minutes ago, Lunah said:

In our syringe cabinet, the insulin syringes were next to the TB syringes, and she grabbed the TB syringe instead of the insulin syringe. She went to give 6 units of insulin IV

Some of our local nurses developed a practice of given subcutaneous heparin with an insulin syringe into the abdomen. Their rationale was that there was less bruising. Upon EBP it was found the needle was too short to actually get the heparin into the deep subcutaneous layers of the abdomen but it took us several years to convince the nurses who did this. In addition, it would get the nursing students confused about units versus milliliters in a syringe. Usually syringes have one purpose -- TB, ml, insulin, 60 ml etc. 

[FashionablyL8, CNA, LPN]

OP,  I'm so glad the pt was OK- if the charge hadn't asked about the dosage and caused you to realize your mistake, the patient could very easily have died. I know you are upset about the error but also remember what a blessing it is that your pt lived. If 9mL was given, that was indeed 900 times the amount that should have been given. I think that all nurses should receive training at facilities before giving insulin, simply because most medication is measured in mLs and confusing units and mLs can obvious be fatal. Just a 15 minute refresher/reminder class comparing units vs mL could prevent so many mistakes.

OP, I wouldn't say that you should quit nursing because of this, as long as nursing is what you want to do. 

Best of luck. There is no shame in not knowing things- the important thing is to learn so you can be a safe nurse.