Med Error

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. 

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.

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.

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. 

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 ?

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.  

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).

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. 

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.!

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).

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.

On 1/16/2022 at 1:49 PM, londonflo said:

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.