Medication Error - 53 is this for me

Nurses Medications

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  1. Have you ever mixed up insulin pens before and used the wrong pen on the wrong patient?

    • 6
      Yes
    • 48
      No

54 members have participated

I am a 53 yr. old new grad and just began a substitute school nurse position. I made a medication error and have to go into to talk to the superintendent about it. I used another student's insulin pen to give insulin to a student, unknowingly. Student is fine. Will I get fired for this? I was excited about the possibility of making this a career...Love the kids, schedule and laid back atmosphere. Anyone ever mixed up unlabeled insulin pens before? Should I hang it up and go back to interior design????

I am a 53 yr. old new grad and just began a substitute school nurse position. I made a medication error and have to go into to talk to the superintendent about it. I used another student's insulin pen to give insulin to a student, unknowingly. Student is fine. Will I get fired for this? I was excited about the possibility of making this a career...Love the kids, schedule and laid back atmosphere. Anyone ever mixed up unlabeled insulin pens before? Should I hang it up and go back to interior design????
That's pretty big, but I wouldn't hang it up because of that. I know some great nurses who have done far worse, far dumber, and far more dangerous. If this is a trend...okay...but if you're loving what you're doing and this is an isolated incident and you don't feel like it was unpreventable...learn from it!
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That's a good perspective from which to approach this meeting...Staying focused on the kids safety is really what this is about...So wrapped up in the stress this event has caused me...Thank you and please send good vibes my way at 11 am tomorrow morning!
If they were done with you there would be nothing to talk about. It sounds like there is something to talk about. Good luck to you, and use this as a learning experience!
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I am going to have to dig deep for the courage to explain my actions, let alone be the advocate for changing the system... Although I can imagine being so brave...Your words and these comments are inspiring.

Your mistake was neither HUGE or life threatening. It could have been (I think this is where you are getting stuck) but it was not.

Mistakes do not happen in a vacuum. They are like spikes in a graph, where little mistakes build on one another and KABOOM the big spike, and then it does down. Your personal responsibility in all this is very specific -- you used one kids Humalog pen instead of the other one. This kind of mistake is due NOT to your inherent inability to do nursing, but a system-induced error. You just said the insulin pens aren't even labeled (horror, oh horror). I can see all kinds of ways this error happened and only a fraction of them are your responsibility.

Please take a look at how hard you are being on yourself, it is truly over the top. Go to the superintendent and say "I made an error by using Johnny's insulin pen on Teddy, they're the same exact thing so nothing bad happened. But I see an area where we need a system in place to prevent an error like that happening again. I'd like to get some kind of stick and peel label to put on the kids' unlabeled meds. I feel terrible about this, and think if the pens had been labeled, I wouldn't have made this mistake." Smile gratefully and hopefully he'll send you to a secretary who has a label maker. That's it. Carry on.

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Specializes in Geriatrics, Dialysis.

As the pens aren't labeled there is no way to really confirm the "right patient" once it is in your hand. As long as it was the right med, right dose and given to the patient requiring this med, which is ultimately the right patient I think you are OK. I understand this is still technically a med error, but in this case, no harm done. I am sure as a result of this error you will be much more careful in the future.

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The wisdom of the comments I am receiving is so valuable! I am using the script above and incorporating the other advice....WOW...This is an awesome forum...Great therapy...

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Specializes in Peds/Neo CCT,Flight, ER, Hem/Onc.
Your mistake was neither HUGE or life threatening. It could have been (I think this is where you are getting stuck) but it was not.

Mistakes do not happen in a vacuum. They are like spikes in a graph, where little mistakes build on one another and KABOOM the big spike, and then it does down. Your personal responsibility in all this is very specific -- you used one kids Humalog pen instead of the other one. This kind of mistake is due NOT to your inherent inability to do nursing, but a system-induced error. You just said the insulin pens aren't even labeled (horror, oh horror). I can see all kinds of ways this error happened and only a fraction of them are your responsibility.

Please take a look at how hard you are being on yourself, it is truly over the top. Go to the superintendent and say "I made an error by using Johnny's insulin pen on Teddy, they're the same exact thing so nothing bad happened. But I see an area where we need a system in place to prevent an error like that happening again. I'd like to get some kind of stick and peel label to put on the kids' unlabeled meds. I feel terrible about this, and think if the pens had been labeled, I wouldn't have made this mistake." Smile gratefully and hopefully he'll send you to a secretary who has a label maker. That's it. Carry on.

I really liked this post but the bolded sentence gave me pause. I think that it's never a good thing to say "well I screwed up but nothing bad happened." That can come off in a way you never intended. It might be better to say "I made an error by using Johnny's insulin pen on Teddy. Fortunately, they're the same so Johnny wasn't harmed but I don't ever want this to happen again. I thought about how this happened and realized that none of the pens are labeled..."

Do you get my drift?

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Refining my case. Thank you FlyingScot. Helpful! I have a tendency to beat myself up over things like this, so the balance of perspectives on how to proceed is so helpful. There are lots of details I could recount, and explaining them to a lay person might make my message ambiguous. I will be objective and succinct in my description of the incident, explain that I am owning my mistake and make a recommendation on how the mistake might be avoided. I have information on an FDA Safety Alert about labeling insulin pens that I would like to share with him. I know what to do, doing it another story. Will post how it went.

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I am a 53 yr. old new grad and just began a substitute school nurse position. I made a medication error and have to go into to talk to the superintendent about it. I used another student's insulin pen to give insulin to a student, unknowingly. Student is fine. Will I get fired for this? I was excited about the possibility of making this a career...Love the kids, schedule and laid back atmosphere. Anyone ever mixed up unlabeled insulin pens before? Should I hang it up and go back to interior design????

As a new grad, I think perhaps you lack the experience and perspective to understand that this unlabeling system is bull. Keeping unlabeled meds around is NOT acceptable. They are ridiculous hypocrites if they expect an error like this NOT to happen given this nonsense.

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I love the boldness with which, you very experienced nurses, express yourself!!! Using this incident to practice speaking up for myself and advocating for kids. Still shaking though, dammit.

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Specializes in LTC Rehab Med/Surg.
Pens are not labeled but placed with the student's supplies. Too many details to explain but ultimately my fault.

The last three words of this post is reason enough to keep you.

Honesty and integrity are as valuable as any other skill you have.

I wouldn't fire you, or advocate that you be fired.

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I really liked this post but the bolded sentence gave me pause. I think that it's never a good thing to say "well I screwed up but nothing bad happened." That can come off in a way you never intended. It might be better to say "I made an error by using Johnny's insulin pen on Teddy. Fortunately, they're the same so Johnny wasn't harmed but I don't ever want this to happen again. I thought about how this happened and realized that none of the pens are labeled..."

Do you get my drift?

Your wording is definitely the way it should be presented to the superintendent, I think Gooselady was speaking to the internal dialogue in OP's head and changing her perspective self flaggelation so that she could deliver your good example.

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I am not a school nurse, but just wanted to wish you well as this is resolved. Also, wanted to mention a policy of my son's school nurse in case it may be of any help to you. He has a medication (set of 2 Epipen, Jr. in box) that is kept at school. The nurse requires that an a official pharmacy label and a recent photo of him be attached to the box. Not sure what she does for kids with several meds or with particular med containers/bottles that make this difficult to do. Possibly one separate container to store them so there is label for each but only one photo for all.

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