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?
I have seen 90 units of lantus q hs as a dose. Written by an endocrinologist no less, so giving 100 unit dose would not be out of the question. Although criticial thinking might come into play as the nurse ssaid that the patient having issues with hypoglycemia is not anything new.
I agree with the poster that said that 100 units/mL is a concentration, not a dose. Maybe its because i have a chemistry background but that to me just seems like an oversight to assume that would be a dose.
We have our orders entered on the computer, but still have a paper MAR. I do believe this has happened before seeing this same resident has had his BS bottom out quite a few times.
I would take it as a learning experience...Im an LPN in ltc...nothing glamourous. Anyhow, My 2nd day of orientating I gave someone a tb test that was allergic to it....however, I had no idea she was allergic because it wasnt on the MAR. A day later I pulled out her chart to document something on her and saw it in big black letters on the front of the chart and about had myself a heart attack on the spot I went and double checked the MARS again...wasnt on there at all..so I wrote it on there with a sharpie and did my thing...all was well..but i too was scared of losing my license....nurses arent machines and we are not perfect. Anyone who expects us to be must live in a fantasy world....we ALL mess up and any nurse who ever tells you they've never messed anything up is fibbing lol. usually when we mess up....we dont repeat that same error again. it sticks with ya.
Im sorry but the nurse who gave the insuling is actually the one who had the error whether she was orienting or not. !st rule of injections....Dont give something you don't draw up yourself. What is it about LTC that people just automatically report to the board? is it some written rule.
Isn't all insulin 100u/ml?? I agree, the LPN shouldn't have given something she didn't draw up, and if you only have one type of syring and it's 50u,.then she had to give two full syringes,.always a red flag to double check. Hope everything works out for you.
Insulin is one of the most common medication errors. Much of this is atributed to the was an order is written. We seem to be making it harder than it is. We should have the actual dose to give, the amount of liquid in a bottle is used when math is needed, but a simple dose of Lantus?
OK, I have read all of the posts here, and I still come up with the same conclusion- the nurse was wrong to give 100u of insulin. no matter how it was written, what computer system you used, etc., etc.
IF YOU ARE NOT SURE, GET A SECOND OR THIRD, OPINION! No nurse with the proper training would have not questioned this dose!
It's not a matter of who in the chain of command is to blame; or who is at fault legally, it's about trying to ensure pt. safety, and no; pt. safety does'nt mean simply that they did not die! It means that a pt. is NOT subject to unnecessary interventions because of medical errors. patients have a right to safe care, not hapahazard care that is fixable.
hello guys.. i am a rn in a longterm facility with a bed capacity of 110 and im passing meds to almost 30 residents... im kinda worried because i made a dossage error last two weeks ago.. instead of giving 45mg of morphine i just gave 30mg. i didnt realize that 45mg of morphine will come from two bubble packs..from 30mg and 15mg = 45mg... i just want to ask you guys if im gonna be on trouble if they found out that mistake...? there was no any adverse reaction noted ... please advice.. thanks
LouisVRN, RN
672 Posts
I have seen 90 units of lantus q hs as a dose. Written by an endocrinologist no less, so giving 100 unit dose would not be out of the question. Although criticial thinking might come into play as the nurse ssaid that the patient having issues with hypoglycemia is not anything new.
I agree with the poster that said that 100 units/mL is a concentration, not a dose. Maybe its because i have a chemistry background but that to me just seems like an oversight to assume that would be a dose.