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 ?
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?
This was not an accident.But I do sympathize with the OP.
Whenever you are thinking you should do something you have never done before (and the OP realized this)....stop and think. Get confirmation on not just the theory but what your actions are going to be.
Frankly, It must have been really hard to get 9 ml out of a 10 ml vial. Sometimes things are packaged to prevent errors.
OP, I am sure you are miserable and I truly do feel for you. Use this as a teachable time. Enroll in a CEU program on metabolic/electrolyte problems and the use of insulin. A typical U-100 vial of insulin contains 10 mL, or 1,000 "units" of insulin. Familiarize your self with the difference between insulin U-100 syringes and milliliter syringes. Should anyone question your knowledge you have shown you are active in in improving it.
how is it not an accident? Unless OP decided "hey, I'm purposely going to give my patient the wrong dose" then it IS. The amount of people in this thread that act like they've never made a mistake is glaring. I agree that this is a huge mistake, but nurses make mistakes and all we can do is learn from it.
Agreed! This is a teachable moment. Go back to the Five Rights of Medication Administration: Right Patient; Right Drug; Right Route; Right Time; Right Dose. And always triple check. Check as you are removing the medication, check as you are scanning, and as you administering to patient. I still look at packaging as I am giving to patient and look on their mar to make sure everything is correct. Lately we're having up to 8 patients with no aide and under so much stress, you can never recheck enough to make sure everything is correct.
Agreed! This is a teachable moment. Go back to the Five Rights of Medication Administration: Right Patient; Right Drug; Right Route; Right Time; Right Dose. And always triple check. Check as you are removing the medication, check as you are scanning, and as you are administering to patient. I still look at packaging as I am giving to patient and look on their mar to make sure everything is correct. Lately we're having up to 8 patients with no aide and under so much stress, you can never recheck enough to make sure everything is correct.
how is It not an accident? Unless OP decided "hey, I'm purposely going to give my patient the wrong dose" then it IS.
The OP purposely used a milliliter syringe to draw up 9 ml instead of an U 100 syringe to draw up 9 units. And did not realized the difference from what was being delivered versus what was ordered. And the OP avoided the required the need for a cosigner when the pump required it. BUT when the cosigner was needed,.... thank God she asked about the volume of insulin given. Otherwise the patient would have died... It you cannot understand the difference between 9 units and 9 ml (900) units it is time to reeducate. The action and intention of thinking 9 ml is what was ordered and 9 units is not an accident. Would you have done the same as the OP?
Mistakes are not accidents...what if someone turned their car in front of you while you had a "green" light and they had a "red" NOT yellow, not a fading green, they had been stopped there for quite a while and just turned in from to you! We term this accidents but are they really?
The OP used a milliliter syringe to draw up 9 ml instead of an U 100 syringe to draw up 9 units. And did not realized the difference from what was being delivered versus what was ordered. And the OP avoided the required the need for a cosigner when the pump required it. BUT when the cosigner was needed,.... thank God she asked about the volume of insulin given. Otherwise the patient would have died... It you cannot understand the difference between 9 units and 9 (900) units it is time to reeducate. The intention of not realizing 9 ml is not 9 units is not an accident. Would you have done the same as the OP?
Mistakes are not accidents...what if someone turned their car in front of you while you had a "green" light and they had a "red" NOT yellow, not a fading green, they had been stopped there for quite a while and just turned in from to you! We term this accidents but are they really?
Pleas stop attacking. I accepted my mistake, that is why I posted here and I been punished enough by my director anD myself . I didn’t think 9 unit is same as 9 ml . For some weird reasons I thought order asked me to give 9 ml . As I mentioned before this order came out of regular insulin procedure for me . Since Pt wasn’t diabetic, insulin was orders per kg, and it was IV . So I thought this is odd already , so it made sense at that moment to give 9 ml for a totally different situation that to me at that time didn’t have any relation to insulin and blood glucose level .
I will say this thread has made me re examine my own practice and be extra careful with med administration. Like many units mine is also short staffed, and we are stretched thin but I am re prioritizing to make sure treatments and meds are delivered properly.
Pleas stop attacking. I accepted my mistake, that is why I posted here and I been punished enough by my director anD myself . I didn’t think 9 unit is same as 9 ml . For some weird reasons I thought order asked me to give 9 ml . As I mentioned before this order came out of regular insulin procedure for me . Since Pt wasn’t diabetic, insulin was orders per kg, and it was IV . So I thought this is odd already , so it made sense at that moment to give 9 ml for a totally different situation that to me at that time didn’t have any relation to insulin and blood glucose level .
Sorry if some posters have made you feel this way. It's good you recognize your mistake was a big one and learn never to make the same one. I guess next time if you feel something is "odd" you should double check with someone else. Now you know! I fully believe you didn't purposely want to harm the patient, which is what we all should be keeping in mind when commenting on this post. I would not say nursing isn't for you because of this. Maybe it will take some time for you to develop critical thinking skills. How long have you been a nurse? IDK what unit you work on (if you said it before I apologize) but maybe working on a less acute floor would help for a bit. Take care of yourself, too! You didn't mean to harm a patient but you did. That can be hard mentally to accept.
6 minutes ago, LaurenXo said:
I will say this thread has made me re examine my own practice and be extra careful with med administration. Like many units mine is also short staffed, and we are stretched thin but I am re prioritizing to make sure treatments and meds are delivered properly.
that's awesome! definitely a good thing to take out of this
Pleas stop attacking. I accepted my mistake, that is why I posted here and I been punished enough by my director anD myself . I didn’t think 9 unit is same as 9 ml . For some weird reasons I thought order asked me to give 9 ml . As I mentioned before this order came out of regular insulin procedure for me . Since Pt wasn’t diabetic, insulin was orders per kg, and it was IV . So I thought this is odd already , so it made sense at that moment to give 9 ml for a totally different situation that to me at that time didn’t have any relation to insulin and blood glucose level .
Keep in mind that often on this forum once a thread gets rolling it really ceases to be only about the OP and gets into more general discussion about the topic that was brought up. I don't think people are specifically talking to you or attacking you on most of these posts, but rather just talking about the situation as a whole.
. Since Pt wasn’t diabetic, insulin was orders per kg, and it was IV . So I thought this is odd already , so it made sense at that moment to give 9 ml for a totally different situation that to me at that time didn’t have any relation to insulin and blood glucose level
Education at the moment would have been beneficial. A lot of nurses have recommended additional programs on the treatment of hyperkalemia and given you links. What have you done to increase you comprehension to prevent this happening again in the future? If you want to be a traveler , make sure you really have a through grasp on ALL medical-surgical knowledge to be a safe practitioner. I have shown empathy and sympathy to you but I don't see and sympathy for the patient in your posts.
22 hours ago, Rada said:
Pleas stop attacking. I accepted my mistake, that is why I posted here and I been punished enough by my director anD myself
22 hours ago, Rada said:
. I didn’t think 9 unit is same as 9 ml . For some weird reasons I thought order asked me to give 9 ml . As I mentioned before this order came out of regular insulin procedure for me . Since Pt wasn’t diabetic, insulin was orders per kg, and it was IV .
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So I thought this is odd already , so it made sense at that moment to give 9 ml for a totally different situation that to me at that time didn’t have any relation to insulin and blood glucose level .
" Weird" doesn't belong in healthcare. and you don't still have a clue about the hazard to human life that you did. Thank God for your cosigner.
Please respond what educational activity you have done, many were mentioned above. I wonder if this was a Sentinel act?
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Why is it called a sentinel event?
An event can also be considered sentinel event even if the outcome was not death, permanent harm, severe temporary harm and intervention required to sustain life. Such events are called "sentinel" because they signal the need for immediate investigation and response.
Please let us know what you have done to increase your knowledge in this area.
Londonflo: Are all nursing students still required to take a course in nursing theory? My dream is that theory is reduced to a 2 hours online class and that classroom time be devoted to clinical issues - especially the concept of sentinel events and other topics of a critical issues in each specialty.
Londonflo: Are all nursing students still required to take a course in nursing theory?
At the schools I taught in (over 40+ plus) nursing theory was an hour or two. Not anything like I had in graduate school. Usually nursing theory was used as a framework for care plans. We did spend a few hours on medication errors but I agree we need to spend more time with it. QSEN publishes a lot on this and there is a very impactful video where a near teen goes in for routine surgery and dies. His mother then developed the 'rapid response' system. https://qsen.org/publications/videos/the-lewis-blackman-story/
pinkdoves, BSN
163 Posts
how is it not an accident? Unless OP decided "hey, I'm purposely going to give my patient the wrong dose" then it IS. The amount of people in this thread that act like they've never made a mistake is glaring. I agree that this is a huge mistake, but nurses make mistakes and all we can do is learn from it.