Medication Error - 53 is this for me

[Mindfulone1]

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????

[Mavrick, BSN, RN]

Based on what you have told us, this sounds like a system error waiting to happen and YOU found it. Yeah you! Seriously there has to be a better way and like the above poster indicates a surefire labeling method is what another school nurse has chosen to address the labeling issue.

You have taken the appropriate responsibility for the error now step up, analyze the problem and take responsibility for the solution.

• Too much of a hurry?
  
• Not enough knowledge of the medication?
  
• Distracted by other things?
  
• Couldn't read label?
  
• Poor lighting?
  

I like to think of it as I'm helping the next nurse not make my mistake. After all the bottom line is we really do like to help people.

Your true character shows when you always advocate for the patient. You can live with that.

Welcome to the human side of Nursing!

[Here.I.Stand, BSN, RN]

I agree, there's no reason those pens should not have been labeled. I work in a hospital ICU, and almost all of our patients are Rx'ed insulin pens during their stay--they may not need them, but an insulin sliding scale is a pretty standard order for control of stress-induced hyperglycemia. So anyway, there are lots of identical Novolog pens, each stored in each pt's bin in the med room. Kind of like how your students' pens are stored with their own supplies. They are ALWAYS labeled w/ the pharmacy label which includes the pt's name, DOB, medical record number, Rx'ing provider, expiration date, etc.

Med errors happen. We have ALL made them (unless we are too new to have made one YET). We bear responsibility yes, but it is now known that systems errors are a big contributor. We are encouraged to self-report med errors not to shoot ourselves in the foot, but to learn what these system flaws are and how to correct them. Some examples are no more KCl vials on the floors--it's impossible for an RN to push KCl instead of the vial next to it, if the KCl vial is not there. Heparin coming in standard concentrations--no more 100 u/ml and 300 u/ml.

I'll give you an example from my own work the other day. Pt was on Tegretol elixir b/c she was intubated and getting meds down her feeding tube. She was Rx'ed 200 mg; its concentration is 100 mg/5 ml. There were 20 ml in the syringe sent from pharmacy. 400 mg were in a single-dose syringe. I was responsible for my 7 rights, and I did only give her 10 ml for 200 mg. However, we've been told over and over that med barcode scanning is a safety feature, and an overwhelmed RN might trust that safety feature and not catch that the PharmD-verified dose was incorrect. An RN doesn't give meds in a vacuum.

The policy that meds can be unlabeled is a systems flaw. What if you take one out to administer, and suddenly the principal goes into cardiac arrest and you have to run for the AED? How do you know you've put it back into the right student's bin? Or what if you're out sick, and a sub RN or a health para fills in for you for the day. How do you know that person returned the correct meds to the correct bin? You CANNOT do your 7 rights if the meds aren't labeled, and you're GOING to make errors. This needs to change--for your students' safety and for yours.

[danielle2000, MSN, RN]

Oh please do not leave!!! You have made yourself accountable for this error and now with this you can learn from it and find a systematic way to avoid this from happening again. No one is perfect we all make mistakes and for the most part most of us have learn from them. :-)

[Mindfulone1]

Met with Director of Student Support Services and the RN in charge of hiring subs. They began with "We wanted to start off by saying we've heard a lot of positive things about you." I explained what happened from my perspective and they said, "Well it's out of our hands." The decision is the superintendents. I asked if I could write a written appeal, so I'm doing that now.

[Libby1987]

Another thought, when you write the appeal, don't let a blaming tone come through. We know it was bad lack of policy to not have the meds labeled but you don't want to point out how anyone in the district has been lacking.

[JMCP]

what?!?!?!? they are unlabeled and you're new! if anything, i this the school and you can learn from this mistake and start labeling. there is no need to fire someone. my college professors always said, you need to establish best practice because you'll always make a mistake down the line.... what you want to do, is hope you don't hurt the person in the process and learn from them. so no! don't quit! its defeating i know because we hope to be the best, we never want to make a mistake and much less hurt anyone. however, to think we will never make a mistake is not realistic... you must learn from it and device a plan to not let it happen again. so lick your wounds, get up and try to be the best you can be! cry it out if you have to!

[nurseprnRN, BSN, RN]

Include the copy of the new policy you're going to write up incorporating the many suggestions you have here, and cc your principal and the head nurse of the district BEFORE she hears some distorted view from the superintendent.

[Esme12, ASN, BSN, RN]

Met with Director of Student Support Services and the RN in charge of hiring subs. They began with "We wanted to start off by saying we've heard a lot of positive things about you." I explained what happened from my perspective and they said, "Well it's out of our hands." The decision is the superintendents. I asked if I could write a written appeal, so I'm doing that now.

I'm confused.....the RN in charge isn't outraged that these pens go unlabeled? She isn't on the band wagon of labeling the pens and developing a new policy that protects the safety of the students and IS CONSISTENT with the STANDARD OF CARE AND FDA ALERT RECOMMENDATIONS? Shame on her.

Recommendations and Information for Healthcare Professionals Regarding Insulin Pens and Insulin Cartridges, and other reusable injector devices:

[*=left]Insulin pens containing multiple doses of insulin are meant for use by a single patient only, and are not to be shared between patients.

[*=left]Identifying the insulin pen with the name of the patient and other patient identifiers provides a mechanism for verifying that the correct pen is used on the correct patient, and can help minimize medication errors. Ensure the identifying patient information does not obstruct the dosing window or other product information such as the product name and strength.

[*=left]Be aware that the likelihood of sharing insulin pens and cartridges is increased when the pens are not marked with the patient name or other patient identifiers.

[*=left]The disposable needle should be ejected from the insulin pen and properly discarded after each injection. A new needle should be attached to the insulin pen before each new injection.

[*=left]Although the incident leading to this FDA alert occurred with insulin pens, the same risk may exist with shared use of any reusable injection device.

[*=left]Hospitals and other healthcare facilities should review their policies and educate their staff regarding safe use of insulin pens.

While the superintendent has jurisdiction over your position he does not have jurisdiction over your RN practice. I can't imagine that he is familiar with FDA alerts and recommendations for safe practice

Medication Administration in the School Setting (Amended January 2012)

http://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=92

http://www.ismp.org/NEWSLETTERS/nursing/default.aspx

[rollernurse365]

I do not know any good nurse who hasn't made some mistake with potential to cause harm. Whatever happens with the Superintendent, do not leave the profession. We need nurses with integrity who can learn and teach from their experiences, good or bad. I wish you all the best.

[Mindfulone1]

Extremely helpful ESME12!!! Taking this info and running with it...

[Mindfulone1]

Thank you...I love you guys...

[roser13, ASN, RN]

Thank you...I love you guys...

Please come back & update us after you meet with the Superintendant.