Med Error

Updated | Posted
by Rada Rada (New) New Nurse

Specializes in med surge.

You are reading page 4 of Med Error. If you want to start from the beginning Go to First Page.

ladedah1

ladedah1, BSN, RN

Has 7 years experience. 91 Posts

I'm so sorry that this happened to  you (and your patient).  We all make mistakes.  I don't think you mentioned how long you've been in nursing, but I do know that the clinical experiences and new RN orientations have been suboptimal during this pandemic; if you are newer to the field, this definitely wouldn't have helped.

It does sound like you did the right thing in following up right away once you realized your mistake, which enabled the patient to get to the right level of care and offer the best odds given the situation. 

Sometimes things learned the hard way are the ones best remembered.  In the future, I would advise that any time you give something with which you are unfamiliar (especially IV), check with your charge regarding administration policies (or check the policies yourself if he / she / they are busy), double or triple check the dosage and instructions yourself (before, during, and after drawing it up), then click accept on the MAR to see if it flags for a double check before administering. 

I've been a nurse for quite a while now, but when I'm floated to another unit and see a med I've never given, I still always question the rules surrounding administration... some meds, for instance, require ACLS Certification to administer (which I'm not) and would require charge to administer despite the lack of flagged double check.

Anyhow, please don't see this as a reason to give up on all the work you have put into your career. Keep your head up!

Edited by ladedah1
Typo

subee, MSN, CRNA

Specializes in CRNA, Finally retired. Has 50 years experience. 4,282 Posts

On 1/15/2022 at 12:18 PM, kp2016 said:

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. 

Punitive education?  When is education EVER punitive?  There was a definite lack of knowledge in this serious error and reviewing all the aspects of safely administering insulin is not out of order here.  The OP reported herself and that was the most important step in making sure that proper remedial steps are taken.  Punitive education - what a concept:(

subee, MSN, CRNA

Specializes in CRNA, Finally retired. Has 50 years experience. 4,282 Posts

On 1/18/2022 at 6:39 AM, Rada said:

Yes. It was IV push 

I know this is an aside but you might want to change your job description to "specializes in med surg".  There is no e in surgical.

AlvaRN

AlvaRN, BSN

Specializes in Public Health. Has 19 years experience. 1 Post

I'm glad you identified your mistake right away and took steps to ensure your patient's safety. Yes, you made a mistake. This is a valuable lesson for you and I hope at your next position you will feel empowered to ask questions and seek guidance until you truly understand what you are doing and why. 

At my very first nursing position one of my colleagues (we graduated from ADN school together and we were working on the same unit) made a near fatal medication error with a narcotic. She never returned to nursing. I would encourage you to consider the error you made and ways to avoid similar errors in the future. 

Although it has been some time since I have worked in acute care, there were always hard stops before administering high alert medications such as insulin or heparin. Even if there isn't one in your facility it may be wise to consult a second nurse before administering to be sure you are reading the order correctly. I wish you the best in the future. Please never be afraid to advocate for yourself for the education and training you need to practice safely. 

Robmoo

Robmoo, ADN, BSN, RN

Specializes in BSN, RN, CVRN-BC. Has 26 years experience. 142 Posts

So you over-road the built in safety systems by giving insulin before the double sign off and then you gave a 100 fold overdose of insulin.

Reporting to the BON is that director's responsibility.

You need to do some remedial education regarding the use of insulin.  The lack of knowledge regarding the role of insulin/dextrose role in driving potasium back into the cell is a secondary issue here.

If he does report to the BON the fact that you sought out remedial education on your own will be a BIG plus in your favor.

I don't think that you have enough nursing experience to be working as a traveler.  You need a couple more years of experience.

I would not recommend that you quit nursing.  However, you need to seek education and experience so that you can become a safe nurse.  I would recommend a regular hospital job where you can find an experienced mentor.

Good luck and for the sake of our patients be safe.

Justcultureisjustcrap

Justcultureisjustcrap

Specializes in Vascular access. Has 39 years experience. 27 Posts

We ALL make mistakes.  But, don't believe the "just culture" crap.  Absolutely a lie . Don't give up. You dedicated a lot of your life to this goal. The good thing about nursing is that you don't have to work in a hospital . That's what I told my daughter, who I talked into going into nursing. Explore your options. Good luck.

subee, MSN, CRNA

Specializes in CRNA, Finally retired. Has 50 years experience. 4,282 Posts

32 minutes ago, Justcultureisjustcrap said:

We ALL make mistakes.  But, don't believe the "just culture" crap.  Absolutely a lie . Don't give up. You dedicated a lot of your life to this goal. The good thing about nursing is that you don't have to work in a hospital . That's what I told my daughter, who I talked into going into nursing. Explore your options. Good luck.

What does this mean?  What is "just culture crap?"  Do you think that she shouldn't work in a hospital?

Justcultureisjustcrap

Justcultureisjustcrap

Specializes in Vascular access. Has 39 years experience. 27 Posts

We ALL make mistakes.  But, don't believe the "just culture" crap.  Absolutely a lie . Don't give up. You dedicated a lot of your life to this goal. The good thing about nursing is that you don't have to work in a hospital . That's what I told my daughter, who I talked into going into nursing. Explore your options. Good luck.

Justcultureisjustcrap

Justcultureisjustcrap

Specializes in Vascular access. Has 39 years experience. 27 Posts

What does it mean? It means exactly what I said. I never said she shouldn't work in a hospital and don't twist my words. I was suggesting that she might want to explore other nursing options besides the dog-eat-dog world of hospital nursing where people can't wait to "tell" on you or report you or take your license. That's what I mean by "just culture is just crap". Because it is. Don't be fooled by it 

Camillemm

Camillemm

17 Posts

I am sorry this happened.  But please realize nursing is a human driven profession.  Humans make mistakes.  Your director 's response goes against everything we are taught as nurses about medication errors...... honest errors are ultimately learning experiences and should not be responded to in a punitive manner.   You want nurses to do what you did, report the error right away and safe guard the patient.  Responding punitively will make errors less likely to be reported.  Every institution knows this. There has been study after study documenting this.  Of course you feel terrible, we all do when it happens.  But you did the right thing, by recognizing and reporting your error.  I do not think that this is something that needs to be reported to your state nursing board.  Your director is using intimidation.  If it needed to be reported that is something the hospital would do.  I would guess you will never make this type of error again.  God bless you.

Gooday

Specializes in RN, DSD. Has 27 years experience. 38 Posts

Every one makes errors of some sort if your a nurse for any amount of time.  Don't quit,  when you make an error it causes you too become hyper vigilant.   Quite often the best teacher are people who have made mistakes.  I worked at a place were a new nurse was being oriented and she made the same kind of insulin mistake,  she was a new nurse and she should not have been allowed to do anything alone for at least a few weeks.   In that incident the preceptor was fired,  a new grad should be observed and checked off on every skill.  If someone is asking me how to do something I go and show,  even a traveler should be observed for at least a few days checked off. If you have never done it ask for help no matter how long you have been a nurse.  Some supervisor's will not want to teach you, if they don't want to teach you or show you how to do something you have not done let them do it.  If that little voice in your head says I don't know about this, something's wrong,  listen....  Its like when your taking the NCLEX the first thing that pops in your head is usually right.  If you brain says ask for help or Im not sure ask for help.   I have been a traveler, if you don't know how to do something push the issue don't wing it.   Get help.  

Edited by Gooday

londonflo

londonflo

Specializes in oncology. Has 45 years experience. 2,192 Posts

4 hours ago, AlvaRN said:

I'm glad you identified your mistake right away

The cosigner identified the administration of 100 times the insulin dose. I truly feel sorry for the OP but 'traveling" is not for them. I really hope the OP follows the suggestions of Continuing Education here.