My First Med Error

[Lorrie34]

I graduated LPN school in Dec and started working as a GPN a few weeks ago. When I was in school they taught us to ALWAYS have a 2nd nurse verify Insulin before administering. I was taught that this is required across the board.

I'm in a state of culture shock at how daunting it really is to do a med pass when visitors, aides, and patients are constantly interrupting you as you stand at the cart trying to prepare meds and sign the MAR. On top of that, I have learned that in the "real world"--no, a second nurse doesn't really verify Insulin. Some will go through the motions to put you "at ease" but they don't really check it like they should....why? Because it doesn't matter to them--it isn't their butt on the line if they say what you drew up is okay and you give it and something goes sour, it's your butt on the line, not theirs. Therefore, most of them just laugh at the green nurse that asks for Insulin verification.

So lastnight here I am doing my heaviest med pass of the shift and I'm getting bombarded from every direction...a new admission before I started the pass which made me latem getting started. Then because I was late starting, I had to check my blood sugars as I went. It turns out the 6 I had before that all had non-compatable Insulins to be administered....so I'm drawing up 2 Insulin injetions on one patient and sticking them twice. Then I'm getting the "Oh honey, can I get a pain pill....sleeping pill....tylenol..." in every room and it's one of those units where the roomate has to ask for a pain pill if the person in the other bed asks for one. This was my first night on this shift.

Standing alone at the cart and trying to get everyone medicated and covered within my time limit, it happened...I checked her blood sugar and went to draw up the Insulin. I looked at the MAR, and a patient pokes her head out of her room to ask me to check her colostomy bag..."right away". I tell her I will be in shortly, look down again and see the order for 70/30 every day. I draw it up and off I go to administer it. I give it to the patient and she says "that was a big shot tonight, how much did I need?" (she is blind) I reply "Your usual dosage that you get every day." she says "Noo, that's just in the mornings. I just get covered at night." The blood drains from me and I go to the MAR and look again only to see the two little words that made all the difference in the order..."at breakfast". I immediately found my mentor and told her of what happened. We informed the supervisor and she called the doctor who gave orders to monitor her for the next 24 hrs around the clock.

I gave her 3 glasses of OJ and sugar for the remainder of the shift (which was only 2 hours) and I checked her again 30 minutes before my shift ended and she had already dropped 100 points. She was by far not in a hypoglycemic state, but 100 point drop in 2 hours with 70/30?? I'm terrified.

I should have taken my time and read my MAR and not been in such a hurry. I should have found my mentor and begged her to verify me before I administered. What was I thinking and how could I be so stupid and careless?

I spent the rest of my shift crying my eyes out. I wanted to stay the night in her room to make sure she didn't bottom out through the night. My oncoming nurse promised me he would stay on her with the OJ and sugar and her readings, but it's easier said than done.

I so badly want to call in today (my scheduled day off) and ask my DON if the resident is okay...but I know that we aren't allowed to do that because it violates HIPPA but I am seriously sick to my stomach and can't stop crying. I don't think I should be a nurse after this incident. I could have killed her. I'm terrible.

[SuesquatchRN, BSN, RN]

Oh, honey, stuff happens.

You informed everyone and reported yourself. The physician knows. You are an ethical, responsible burse. The patient is being monitored and is, I am sure, just fine. Enjoying graham crackers and orange juice.

Let it go and learn from it.

:)

[RNBearColumbus, BSN]

Please take a deep breath.

Now.. Let me tell you a story about another new nurse. Once upon a time, there was a brand new LPN who was trying to learn a new unit, pass meds, and learn the names of all of his ...er...their patients. This new nurse prepared the meds for a patient, Mrs. B, and got distracted by a family member asking questions, then an aide needing help, and another patient needing a pain pill.

The nurse finally was able to get back to giving Mrs. B. her meds, and gave them. The patient taking the meds looked at the new nurse and said: "Gee, I don't usually take this many pills." The new nurse simply shrugged and said "It's the same amount you take every morning." The patient took all of the pills at once, swallowing them with a big drink of water.

Turning back to the MAR, the new nurse realized that it was actually MRS. D that had just taken MRS. B's pills. The new nurse froze. If there was ever a deer in the headlights moment, this was it. He quickly called the CNP on call, gave her a list of all of the meds Mrs. D had been given in error, and waited for the CNP to explode and demand that the new nurse leave immediately and never darken the doors of nursing again!

Well, that didn't happen. The CNP chuckled, asked a few questions, then instructed the nurse to check the patient's BP every hour for the next 8 hours, and to make sure that in the future he took his time and verified meds as he had been taught in school.

The CNP assured me er.... I mean The nurse, that while this was the first med error they had made, and it was a potentially harmful error, that it would not be the LAST error the nurse ever made. The important thing is to make sure the patient is safe, learn from the error, and NOT BEAT YOURSELF UP OVER IT.

Ok, I admit it. the new nurse was me. And the CNP was right. It wasn't the last med error I ever made. But I DID learn from it. And you did too. You handled the error the right way. Trust me. Every nurse has a story similar to this one. (Even if they don't admit to it. )

Making a med error does not make you a bad person, or a lousy nurse. It makes you human. Being a new nurse is stressful, and I'm sure that there are moments that you think to yourself that you will NEVER get this. But you will. The fact that you are so upset about this shows that you have a conscience and will be on the lookout for such things in the future. Much better than the nurse who says "Oh well, no one died!" and moves on.

[vanlo001]

I can only speak from my own experience but I and all the nurses I know take the independant double check seriously. I have caught mistakes and have had others catch my mistakes with regArd to insulin. Usually it's not a huge mistake but there is a reason that these meds have been deemed high risk. That being said, protect yourself. Ask for the independant double check even if you feel they are looking down at you. It seems to some extent you are shifting blame to the double check and how busy the unit was etc. That us the reality of your job. Accountability is really important as a nurse and accepting that under these circumstances you missed something vital. Be grateful the patient noticedeland last thing the double check doesn't always save you. Even when you have another nurse double check they mau nit have seen those two words either. Hopefillyyou wrote up an incident report. IR are not meant to be punitive. They are to track errors perhaps the way the MAR appears could be changed to highlight IN THE AM.

[ghillbert, MSN, NP]

Now you've learned a major lesson and you were lucky - the patient was likely ok. Never forget that feeling, because we do truly have lives in our hands. I'm not going to beat you up, because I couldn't tell you anything you haven't told yourself since this happened!

Checks are there to stop us repeating other people's errors. Don't worry if people laugh at you checking things, it's YOUR license and YOU that needs to sleep at night. I often got laughed at for refusing to draw things up and leave them out for the next shift to give, or refusing to give insulin shots at 0600 with nobody to check them in my first RN job at a nursing home. It's hard to stand up for yourself, but it just has to be done.

Be gentle to yourself. You were honest and ethical in your actions post-error and you'll learn from this.

[TheCommuter, BSN, RN]

When I was in school they taught us to ALWAYS have a 2nd nurse verify Insulin before administering. I was taught that this is required across the board.

Verification of insulin and other high risk medications by a second nurse is only required in JCAHO accredited facilities. Virtually all U.S. hospitals are accredited by JCAHO, so insulin needs to always be verified by 2 nurses in the acute care hospital setting.

However, the vast majority of nursing homes and other long term care facilities are NOT accredited by JCAHO. Some are, but most are not. Therefore, nothing is mandating the nurses in these unaccredited facilities to double check insulin dosages with another nurse, unless a rule is specifically written into the nursing home's policy and procedure manual. This is the way it is in the real world of nursing homes.

I'm sorry that you are going through this. We are all imperfect human beings who err at many points in our lives. I'm assured that your resident is okay. Good luck to you!