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Discussion

Med Error

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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? 

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    We use insulin pens for all pts. I can easily see someone getting confused. Esp is you are already feeling stressed and uncertain.

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    On 1/24/2022 at 11:33 AM, 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 . 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 haven't seen much in the way of attacks.  I have seen a few posts regarding the seriousness of the error.  Have you done some education regarding insulin and IV inulin use? 

    Please don't leave nursing.  Have you taken steps to get a regular job at a local hospital in a unit where they have at least a few more experiences nurses who can act as mentors?  Frankly, I've seen quite a few nurses take agency or travelers jobs before they even had a year or two of experience.  That just isn't a good situation. 

    I've seen worse mistakes.  Hang in there and please seriously consider following this advise.  Most of us have been there as far as making mistakes.  Experience and following the patient care protocols are two major factors in preventing serious errors.

    Good luck!

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