Medication errors

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Ok, so I've been an RN for 2 years. I've worked in both an acute care facility and a LTC facility, which is where I'm currently at. Last week, I had an LPN orientee with me. We always would pull the meds together while the orientee would give them so she could put faces and names together. At our facility we recently just went to the Point Click Care computerized charting. A lot of people are still learning it, so it's caused some confusion. So here is the problem.On the night in question, I was pulling meds on a resident on a hall I had never worked before and had the orientee with me. When it came to his Lantus order it read Lantus, SQ Dosage 100 units/ml, Do not shake vial, roll gently, date after opening vial. 10 units. There were a few other things that are facility specific that we include in our orders also. So I did what I've always done, looked at the resident name, looked at the medication, the time it was to be given and looked at the dosage (keeping in mind, it says 100 units/ml). In one of my previous jobs at the hospital, we regularly gave that much Lantus at a time, so I really didn't think much of it. I drew up the 100 units, and set it aside while I went about pulling the rest of the meds. About the same time the LPN orientee gave the Lantus, I saw that 10 units down at the bottom mixed in with a bunch of other garble. I owned up to my mistake. The resident suffered no harm, other than having his blood sugar drop a couple times, but this is also a regular occurrence with this resident. I'm the one though that had the incident faxed to the state board of nursing, while nothing happened to the LPN and my dept. heads, DON took none of the responsibility for it considering they are the ones that didn't remove the 100units/ml like they were supposed to and just added the dosage in elsewhere. Now since this is a first offense, do you think I'll lose my license over this?

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Specializes in Gerontology.

I don't think you'll lose your license over one error.

However - its not the DON's error. Its yours. You did not read the entire order and you gave very large dose of insulin. 100 units/ ml is an important part of the order - you need to make sure you are using the correct syringe to get the correct doseage.

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Actually the DON told me herself that the 100units/ml is not suppopsed to be under dosage (and we only use one kind of insulin syringe....the 50unit syringe), that 100 units/ml is supposed to be taken out and the dosage put in under dosage and the 100 units/ml goes elsewhere, then tried to say someone put the order in the computer wrong, however, the DON or one of the other Dept. heads are the ones that put it in incorrectly. I did speak with the RN board and they said with the system we use, the person that put the order into the computer is also at fault. I admitted that I drew up the wrong amount and that I should have been the one to actually administer it. But the LPN that gave it was supposed to also check the order and the dosage. I admit the ultimate blame, it's just there are other factors involved.

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In all of our insulin orders, it has the dosage (100 u/ml). Just like any other liquid med, that's important info. I would not have given 100u without checking and double checking that order against the written chart. I'm sure your license will be fine...

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Specializes in Maternal - Child Health.

There is another current thread about Pharmacy now doing MARs in the poster's LTC facility and the incredible number of mistakes, due in part, to the confusing way the orders are transcribed.

As I read your post, I could see the error coming.

I suggest you make a concerted effort to work with your facility to revise your MARs to eliminate the possibility of this type of error from happening again due to confusing wording.

Show the BON that you accept responsibility for your mistake, but that you want to change the system that fostered the error in the first place.

I understand your frustration at being reported to the BON when other weren't, but pointing fingers at others will not go over well at the BON. Constructive action will.

Best to you.

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Being reported to the BON for a med error, is that a common occurrence in LTC?

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Specializes in LTC, Psych, M/S.
Being reported to the BON for a med error, is that a common occurrence in LTC?

I was wondering the same thing.

My LTC is just now starting to use a computerized mar system. There are all kinds of indiscrepancies - but I'm used to that, been a RN 5 yrs now. Sometimes the battery on the comp dies so I can't sign the meds out on time. The 'computer lady' came to me the other day and told me that 'the state considers that to be a med error.' I tried to explain that they were just signed out late and that the prob was w/ the comp. Being reported to the state for med errors is new to me - what is going on with this?

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Specializes in home health, dialysis, others.

1. 100/ml is not a dosage.

2. 100 units of Lantus is a very high dosage.

3. You should never give meds poured by someone else - except in a code or similar situation. (In this case, the LPN)

4. Other insulin orders may have been written the same way - how were they dealt with?

5. The resident DID have consequences - low blood sugar that had to be dealt with - multiple times.

6. You are unlikely to be reported to the BON. But you may be written up.

Learn from all this.

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Part of the error is yours. Yes, it read 100units/mL, but it also stated 10 units. 100 units is a huge amount of lantus to give (although I have given that much before), and you should have double checked that anyway. The way that it was stated in units/mL should also have given you pause, if your dosages typically don't read like that. Then again, if it's a new computer system, how do you know how your dosages typically read.

So, as you stated, this wasn't just your error, it was also mis-entered into the computer.

It seems crazy to me that it was reported to the BON. To your facility's risk management, IT, and pharmacy, absolutely. This was your error, the pharmacy's error, and a program error. Reporting it to the appropriate people within your facility is a means of fixing a systemic problem.

As far as your responsibility goes; it is frustrating and disheartening to make a med error. We've all done it. It sounds like you have a good response to it, though: take responsibility for your error, understand how it happened, and don't let it happen again. I'm sorry it was reported to the BON, but after seeing what they investigate, I would be fairly confident that the repercussions will be minor. Not of the losing-your-license sort, but rather either having them completely dropped, or having to take a short class/attend a short seminar/complete an online module on safe medication administration.

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6. You are unlikely to be reported to the BON.

In the original post, it states that she was indeed reported to the BON.

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Specializes in LTC,Hospice/palliative care,acute care.

As others have said the mistake was yours however that's an assinine way to write an order. In my facility whomever took off an order written like that and the nurse that did the 24 hour chart check and then the nurse that gave the med would all be disciplined. If an order came to us from the pharm written in that way we would hand write it correctly.We have policy and procedure (all hail the P and P !!!) covering the exact way orders are to be written and the disiplinary process regarding med errors which is progressive. In my years at this LTC the only times the BON was notified was when actual grave harm occurred to the resident or a pattern of negligent errors and suspicion of medication diversion was apparent (in no way am I suggesting this is the case with you) However if your facility has not followed a clear p and p and errors are being made the dept of health may suggest sending the manner on to the BON and then may cite the facility for lack of good p and p. I'm sure many of us remember LTC back in the day when the same nurses made egregious errors over and over again and it was scary. Our orders are always written with the dosage first then the concentration.We often have to re-write them multiple times depending upon what the pharmacy has available or what insurance covers which seemingly varies from month to month...(all hail Omnicare!!!)

ALWAYS check and double check and check that insulin again....and again for good measure.

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Ok, so I've been an RN for 2 years. I've worked in both an acute care facility and a LTC facility, which is where I'm currently at. Last week, I had an LPN orientee with me. We always would pull the meds together while the orientee would give them so she could put faces and names together. At our facility we recently just went to the Point Click Care computerized charting. A lot of people are still learning it, so it's caused some confusion. So here is the problem.On the night in question, I was pulling meds on a resident on a hall I had never worked before and had the orientee with me. When it came to his Lantus order it read Lantus, SQ Dosage 100 units/ml, Do not shake vial, roll gently, date after opening vial. 10 units. There were a few other things that are facility specific that we include in our orders also. So I did what I've always done, looked at the resident name, looked at the medication, the time it was to be given and looked at the dosage (keeping in mind, it says 100 units/ml). In one of my previous jobs at the hospital, we regularly gave that much Lantus at a time, so I really didn't think much of it. I drew up the 100 units, and set it aside while I went about pulling the rest of the meds. About the same time the LPN orientee gave the Lantus, I saw that 10 units down at the bottom mixed in with a bunch of other garble. I owned up to my mistake. The resident suffered no harm, other than having his blood sugar drop a couple times, but this is also a regular occurrence with this resident. I'm the one though that had the incident faxed to the state board of nursing, while nothing happened to the LPN and my dept. heads, DON took none of the responsibility for it considering they are the ones that didn't remove the 100units/ml like they were supposed to and just added the dosage in elsewhere. Now since this is a first offense, do you think I'll lose my license over this?

minimally, the 100 units/ml should be in ()....and shouldnt be labeled dose....and i have seen very large doses of lantus.....good luck

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