Med Error

[starcandy]

I feel really bad because I gave someone Lantus 100 u sq and through later detection it wasn't ordered. When I first saw the order listed on the MAR I questioned it. I looked in the chart for the order and did not see it. I called pharmacy and was subsequently sent a copy of original order with the patient label attached. I asked the pharmacist whose name I do not remember (learning lesson) if this was a large dose. It was within the dosage range, but on the high end. I checked the dosage range myself within the pharmacy website. and the pharmacist was right . I am thinking that the original order was lost, which could happen . I administered the med and hours later during reconciliation of meds another nurse noticed the same order with the same handwriting on another patient . We compared the orders and it was the exact same handwriting and signatures. We beleive someone sent the order down to pharmacy with the wrong name label attached. I fillled out a incident report and notified the dr. and supervisor which didn't go over well. I should have called the Dr. but when I did notify him after the incident he was also confused on which med the pt was on.

I feel bad because this means I am not a safe and effective nurse I will probably be written uo for this incident. Also the reconciliation process the night before may have caught this error. There were other drugs on the order sheet the pt should have not recieved. When I left in the am the pt bs was in the 130's range.

[Jubei]

Wow...100 units!?

:uhoh21:

Yeah...D50, Glucagon IM, a gallon of OJ, and etc. :)

I've made med errors plenty of times. Crap happens when you're a chicken without a head.