Med Error

I got an order to give insulin IV , Dextrose and calcium gluconate due to a critical k . This order was so weird to me I never heard about it . I asked the charge and said insulin and dextrose are apposite ? She said yes , they will balance each others . It was my first time to give IV insulin . Order said 9 unit and I gave 9 ml . It was made sense to me at that time because I thought if it was unit still I will give subcutaneous. Also it was unit per Kg and I don’t know how I read ml instead of unit . When I administered the medication and presses the accept bottom then the double sign off popped up . I got the charge and said I already gave the med . She asked did you gave 9 unit ? Then I noticed that I made mistake . I called Dr and they sent the patient to ICU for close observation. Luckily pt survived but The Director was so mean to me , she yelled at me , told me to call nursing board and report myself and he canceled my contract with that hospital. I know. Did a huge mistake but if we lose our job for every mistake that we confess ourself , no nurse will be left . I have decided to say goodbye to nursing . What you think ? Should I ? Nurses General Nursing

Updated:   Published

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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? 

Specializes in oncology.
On 1/16/2022 at 1:48 PM, Rada said:

I am well familiar with insulin syringe and insulin .

No you are not as familiar as you thought you were. There are a lot of suggestions of learning programs, articles and CEUs.  Best wishes but accept your learning needs.

4 Votes

I am confused about the co-signer catching the mistake after administration, the entire point of co-sign is to catch a potential mistake prior to administration of the med not after. So I wonder if OP was also skirting policy on getting a double check. 

It's honestly frightening to see someone say they are well versed in insulin and insulin syringes then draw up 9ML of insulin. 10ML syringes are noticeably bigger then even a large insulin syringe. 

Everyone makes mistakes but I agree with the sentiment of others that seeking out remedial education on your own accord will always look more favorable on you. 

 

 

5 Votes
Specializes in BSN, RN, CVRN-BC.
14 hours ago, LaurenXo said:

I am confused about the co-signer catching the mistake after administration, the entire point of co-sign is to catch a potential mistake prior to administration of the med not after. So I wonder if OP was also skirting policy on getting a double check. 

It's honestly frightening to see someone say they are well versed in insulin and insulin syringes then draw up 9ML of insulin. 10ML syringes are noticeably bigger then even a large insulin syringe. 

Everyone makes mistakes but I agree with the sentiment of others that seeking out remedial education on your own accord will always look more favorable on you. 

 

 

Ovier-riding the safety systems that are in place to protect the patients is a HUGE red flag.

Yes, as humans we all make mistakes.  How many have made a mistake of this magnitude?  This mistake cries out for remedial education and working in the evironment where one has more experiences nurses to guide one.  Don't quit, but get safe.  Take the safety systems seriously and if you don't know, ask until you do know.

I don't think that this situation would have occurred in a pre-covid environment.

4 Votes
Specializes in being a Credible Source.

For what it's worth, I once made a much worse med error than that. Pt didn't die but could have had some permanent damage... nobody could really say one way or the other.

It was tough for awhile... and all these years and countless successes later, still hurts a little... but it sure did make me a much more careful nurse. I was already pretty careful, and pretty knowledgeable, but it was just one of those swiss-cheese things where all the holes lined up and there I was with a syringe in my hand.

The boss was an a-hole, pure and simple. No need to be a Richard and pile on to someone who already feels about as bad as one can. That's his thing, not yours. Some people treated me poorly after my mistake and certainly compounded the pain involved, needlessly so. I concluded then, and still do now, that it was their self-defense mechanism to try to convince themselves why it could/would never happen to them because they weren't so incompetent or careless or stupid as they decided I was... except that I was none of those things and yet... the mistake still happened.

So, quit nursing or not? Your call, of course, but this situation is a lousy reason to decide to abandon a career... especially given that you will be one of the safest med nurses ever after this.

Also, I just want to point out (if nobody has) the responsibility that the facility bears if its culture is one of doing a "double check" AFTER the insulin is given... kinda defeats the purpose, right?

Anyway, you will probably feel better over time... I wouldn't use this moment to make such a drastic decision as leaving nursing altogether.

6 Votes
Specializes in Psychiatry, Community, Nurse Manager, hospice.

Good discussion.

We should give empathy and education at the same time and both are equally important, because if education is delivered without empathy it doesn’t work.  You can’t learn something from someone who hates you and thinks you don’t deserve to have the knowledge to do the job right. That person can’t teach you.

The director messed up too. No, you don’t report yourself to the board. You commit yourself to never making that mistake again. 

 

4 Votes
Specializes in Community Health, Med/Surg, ICU Stepdown.

Have others given IV insulin on a Med/Surg floor? When I worked Med/Surg we had to transfer pts to Stepdown or ICU for IV insulin or insulin drip. I was very familiar with giving sub q insulin on Med/Surg but I needed further training when I transferred to Stepdown before I was allowed to give IV push insulin and definitely before being allowed to manage an insulin drip.

The order may not have been appropriate for a Med/Surg floor, but either way I am glad your patient survived, and it's a great reminder to slow down no matter how crazy things are, and ask for clarification if you're not sure/have never done something before. I know it's hard because finding someone to clarify an order with, and taking the time to do it can seem impossible on a crazy busy day, but it is always worth it ?

4 Votes
Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

I'm not sure an education about the difference between a ml and a unit would be helpful.  This was learned the hard way.  Often this is how we learn on the job after school.  Doubtful the OP will forget this.  

Going forward I agree with the poster that one of the more glaring mistakes was the double check was done after administration.  

The other thing is to learn the rationale about this treatment for hyperkalemia. When doing things for the first time it is important to talk to experienced nurses and use resources and take your time to understand it. Nowadays that's as close as our phones.

I'm glad the patient was okay.  

2 Votes
Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.
5 hours ago, LibraNurse27 said:

Have others given IV insulin on a Med/Surg floor? When I worked Med/Surg we had to transfer pts to Stepdown or ICU for IV insulin or insulin drip. I was very familiar with giving sub q insulin on Med/Surg but I needed further training when I transferred to Stepdown before I was allowed to give IV push insulin and definitely before being allowed to manage an insulin drip.

The order may not have been appropriate for a Med/Surg floor, but either way I am glad your patient survived, and it's a great reminder to slow down no matter how crazy things are, and ask for clarification if you're not sure/have never done something before. I know it's hard because finding someone to clarify an order with, and taking the time to do it can seem impossible on a crazy busy day, but it is always worth it ?

Insulin drips where I work are always in a critical or step down unit.  However, treating hyperglycemia with insulin and dextrose can be done where I work if the patient is otherwise stable (and hopefully on telemetry).

1 Votes

I received the same order the other day and had to stare at it for a bit. I was unfamiliar with the hyperkalemic protocol and my error WOULD have been giving the insulin subQ but the checks built into our system stopped me and I gave it IV push, correctly.

Yeah, 9 mLs of insulin is pretty crazy but whatever.

PLEASE PLEASE PLEASE forgive yourself and move on. Seriously. 

1 Votes
Specializes in oncology.
On 1/21/2022 at 4:39 AM, Tweety said:

I'm not sure an education about the difference between a ml and a unit would be helpful.  This was learned the hard way.

When I taught Pharmacology we provided students with both insulin and ml syringes and educated the students on the difference.. We had the students draw up from a vial (for fake insulin).  After a break we had them use their ml syringe to draw from an ampule (filter needed provided.) Each endeavor was demonstrated and adequate time allowed. This was NOT a hard way to teach students...expensive but beneficial. Students learned dexterity and the appropriate choice of a syringe for the medication order. I can guarantee you in my basic education in 1977 we had less 'hands on practice' and with regard to Insulin syringes; we had the old style vials with blue, green and yellow that corresponded to the insulin concentration in the vials versus the Orange syringes and orange top vial == 100 unit per ml. 

I will encourage all of you that your ADN programs need help....Run for  Board trustee...You will be able to change things.....Oh I know your very busy, but make a difference at your one meeting a month.!

3 Votes
Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.
15 hours ago, londonflo said:

When I taught Pharmacology we provided students with both insulin and ml syringes and educated the students on the difference.. We had the students draw up from a vial (for fake insulin).  After a break we had them use their ml syringe to draw from an ampule (filter needed provided.) Each endeavor was demonstrated and adequate time allowed. This was NOT a hard way to teach students...expensive but beneficial. Students learned dexterity and the appropriate choice of a syringe for the medication order. I can guarantee you in my basic education in 1977 we had less 'hands on practice' and with regard to Insulin syringes; we had the old style vials with blue, green and yellow that corresponded to the insulin concentration in the vials versus the Orange syringes and orange top vial == 100 unit per ml. 

I will encourage all of you that your ADN programs need help....Run for  Board trustee...You will be able to change things.....Oh I know your very busy, but make a difference at your one meeting a month.!

With the current rate of DM in the US, I'm pretty sure most schools educate in how to draw up insulin and what a unit vs. ml is.

I meant that the original poster has learned the hard way to pay more attention to 9 ml vs. 9 units.  Lesson has been learned, and sending the person back to a class to learn the difference between a ml and unit wouldn't be necessarily needed at this time.  I'm sure the poster gets it now and will never do it again.

I've learned the hard way many lessons in nursing (and life for that matter).

2 Votes
Specializes in Private Duty Pediatrics.

Yeah, I've made mistakes, too. I once gave my patient's meds to his roommate! It turned out OK, after I told the patient and his doctor. In my case, the meds didn't harm him, but it was still a major mistake.

OP, you can move on from here; don't make any decisions right now about whether or not to continue in nursing. Once the static clears, you will feel much better. 

You made sure your patient got the care he needed. You won't make that mistake ever again. You will most likely be very careful with insulin in the future. You have the opportunity to use some of the excellent education apps that have been suggested. 

It's a hard thing to go through, but it can be done, and you can continue to improve your skills.

2 Votes
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