First big med error....feel terrible!!!

[MarcyRN3385]

About a week ago I had a patient came to our unit after a peripheral angiogram (I work on a med-surg unit). The patient was quite lethargic but began to come around a bit after he got settled in his room. He was diabetic (type 2). I got a set of VS and checked his blood glucose which was 83. The patient also had a dinner tray brought down with him from recovery. With is 6pm meds he had glyburide scheduled. I went ahead and gave it thinking he was going to be eating. Well, he fell asleep. I work 7a-7p so I reported of to the next nurse coming on at 7. Well, the patient's blood glucose ended up bottoming out and they had to give him an amp of D50 that night. Throughout the next day he was practically non-responsive according to the staff (I wasn't there the next day). Normally a peripheral cath patient is discharged in the am after the procedure but d/t his hypoglycemia he had to stay an extra day. This is all my fault and I feel TERRIBLE! I have been a nurse for 1.5 years and this is my first major med error. I am beating myself up about it and keep asking myself....what was I thinking? I also failed to check the order which stated to hold the glyburide if blood glucose if below 150! I feel absolutely horrible! My NM told me not to stress about it...it happens...but if I would have just doubled checked my orders it wouldn't have. From now on my orders will be VERY thouroughly checked before giving ANY med. Has this kind of thing happened to anyone else?

[SuesquatchRN, BSN, RN]

I would calm down and listen to your nurse manager. While you certainly should have checked the hold parameters I never would have thought that glyburide would cause someone to drop like that.

You won't do that again. :)

[MarcyRN3385]

See I thought the same thing...I thought glyburide was more to help maintain blood glucose levels...kind of like lantus does. No...I will NEVER do that again!

[Sniper RN]

I am only a student right now but I had a client this past weekend that was on that med. He was a diabetic with sliding scale insulin. The gyburide was ordered and given regardless of bs levels. One day he did not feel well and did not eat the other he ate 100% of all meals. The med did not bottom him out. Only had to give him insulin once for a bs of 258 gave him 6 units. I would not stress about it. Your patient may have had a hypersensitivity reaction to it.

You already know you made a mistake and you seem like you have learned from it. People make mistakes all the time. As long as you learned from it I don't see why you should continue to beat yourself up about it. He wasn't hurt or injured from it. Move on.

[tokmom, BSN, RN]

Well mistakes happen and of course we beat ourselves up one side and down the other. You learned, so that was a good thing. Big hugs!