The Wrong Dose - A True Story of Medication Error

  1. Safety Nurse sat down with Margo, a fantastic oncology nurse, who talked about the night she gave a patient too much insulin, and he coded. He lived, and Margo is still at the same job. The hospital where she worked supported her and included her in a Root Cause Analysis of the event. Margo is now a well-respected nurse leader at her place of work. In the interview, she opened up about how the error went down, and we talked about the inevitability of error.

    The Wrong Dose - A True Story of Medication Error

    I sat down with Margo in her dining room one evening to talk about a medication error she made when she was a new nurse. I asked Margo to tell me a bit about herself. She hadn't always wanted to be a nurse. She was studying entomology (bugs) at NC State, when the forest service instituted a hiring freeze, so she switched her interest to nursing.

    We talked a bit about the oncology unit where she was hired as a new nurse - we share a bond because I was a baby nurse on the same unit and some of the same nurses who trained me are still there!

    Below are excerpts from our conversation - to get the full interview, listen to the podcast (link is at end of article). I have put all of Margo's comments in italics.

    SN: Tell me about the error

    Margo: I was 4-6 months into my career as an RN, and had finished a 3 month long orientation as a new graduate but was still feeling overwhelmed. The med error started with an accidental duplication of an insulin order. 44 units of Lantus was ordered for bedtime, but there was also an order for 44 units of regular insulin.

    I remember flipping through the order and thinking that it didn't look right, I was still feeling overwhelmed, and it's embarrassing to admit, I wasn't familiar enough with insulin to verbalize to myself why I thought it was wrong. I just remember I knew something was off.

    I had great support from my peers, but I was always asking questions - and I was trying so hard to practice independently.

    I fell into a trap with nurses who make med errors in that I became task focused.
    That's what we teach in nursing schools. We teach tasks because it is so easy to teach and evaluate. In our orientation program, we don't teach nurses how to precept other nurses, and we don't teach nurses how to think critically.

    In my mind I knew something was wrong, but I had to get through the night, and I totally relied on the computer and the system. I remember thinking, there is no way this can be in the computer and be wrong. The NP wrote this order, a pharmacist reviewed it, another nurse checked it...wouldn't the computer catch it?

    I went to pull the insulin from the pyxis knowing something was wrong, but still unable to say why. And I know I shouldn't have given it at all if I couldn't say why it was wrong. I was task oriented and not thought oriented. I pulled up the lantus, and then I went to pull up the 44 units of regular insulin and I remember thinking, this is the part where the pyxis will stop me, but it didn't.

    I walked in the patient room and said, "I have your 44 units of Lantus and 44 units of regular insulin - is this what you do at home?"

    The patient said yes, but who knows why - maybe he was poorly educated, maybe he didn't feel empowered. I wasn't skilled enough to ask open-ended questions, instead I asked for confirmation. I should have asked, "tell me about your home med regimen" instead of asking a yes or no question. So he confirmed, and I gave him the large dose, still knowing something was wrong.

    Part of my reasoning was his previous dosing - he got large meal boluses during the day, and on an oncology unit, we give big doses of insulin to people on high dose steroids.
    I remember trying to justify it...

    I walked past his room about 4 hours after giving the medication. His light was still on, he was laying contorted position, he was unresponsive, seizing and incontinent.
    I called for assistance, and the charge nurse called a code blue immediately. I remember saying over and over, get a glucometer, it's his glucose. We got a reading and it was 12.
    He pulled out his IV while seizing and we had to put in a new one. He was minutes away from him dying or losing all brain function. I had to admit in that moment what happened to save his life. I had to scream "his blood sugar is low, because I gave him too much insulin" while everyone was running around in a panic trying to resuscitate him.
    There was no hiding it - pride could have killed him.

    I hope I never harm someone like that again. I pushed dextrose all night, and the next day there was no discernable loss of function.

    Margo let me know she shares this story with coworkers and with all the nurses she precepts. She wants to emphasize the importance of owning and reporting mistakes, but also of knowing you can recover from an error- it is survivable.

    Margo: I don't think every nurse will harm someone, but you can't tell me there is a single nurse out there who hasn't made some kind of error.

    Margo said she got excellent support from her unit, her manager and the hospital. She was referred to the Employee Assistance Network, but she said after her first Root Cause Analysis session, she felt like that was enough therapy.

    We talked briefly about the new RCA guidelines that recommend not including the person who made the error, and she is strongly opposed.

    Margo: Being involved in that RCA process kept me in nursing. Without it, I wouldn't have recovered from this at all. It was a healing experience for me. RCA helps you realize it's not just you, it's also the system. I got to weigh in on "what will we do next so it doesn't happen again" and I got to design the changes to the programming so it would fix the problem. It was a group of people who supported me and we stood together - we were able to say, "this is what we made so no one has to go through this again"

    I asked Margo for tips on how not to make an error

    Margo: In nursing school, they treat error as something really rare - the Quaid twins with the heparin, the antibiotic being given through the epidural, and the tube feeding hooked up to the IV - sensational cases - so you think, that's what a med error is. I would never do that! I'm a careful person.

    We need to teach nurses, you WILL make mistakes.

    I was precepting a new nurse, and we were talking about med errors, and she said something like, "well I would never do that, not me" and I said, "Well I have. I hurt someone very badly"

    She looked at me like, "why are you telling me this"

    I said, "I hope you never hurt anyone - what is important is to recognize that when you do make an error, you can recover, you can still be here."

    Safety Rules! Podcast is on stitcher, if you don't like iTunes
    Links (what you'll be clicking on if you hit the hotlinks above):
    iTunes: Safety Rules by Kristi Miller, RN, PhD, CPPS, HNB-BC on Apple Podcasts
    Stitcher:Safety Rules | Listen via Stitcher Radio On Demand
    Last edit by Joe V on Jun 14
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    About SafetyNurse1968, PhD, RN

    Kristi Miller just got her doctorate in nursing. She is a certified professional in patient safety, and she just returned from presenting a poster about her research into the effects of Root Cause Analysis on safe medication administration at the Nurse Education Research Conference in DC.

    Joined: Jun '11; Posts: 138; Likes: 361
    Nurse Entrepreneur; from NC , US
    Specialty: Oncology, Home Health, Patient Safety

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    24 Comments

  3. by   Have Nurse
    What a courageous and honest thing you did! We need more like you. God bless you for "owning" it, and turning it into something that can help others!
  4. by   CrunchRN
    Excellent article. All hospitals should handle it like that.
  5. by   hdrn90
    Interesting case for sure
  6. by   azhiker96
    Great story.
  7. by   nosi
    Honesty frees you. This incident, unpleasant as it was,at the time - it made a better nurse
    of Nurse Margo -
    When we learn from ours and other people's mistake we avoid repeating same .
    Thank you for sharing.
  8. by   Jessy_RN
    Great story and very eye opening. I wish my every place was supportive. I for one, have witnessed them drive nurses to shame, guilty and insanity. Placed in front of risk management, interview after interview to tell the same thing. In front of boss, boss with more people, boss with clinical leads, boss with risk management and ultimately a panel of other nurses to shame and condemn instead. Lastly, the nurse has to make a huge poster and present it to his/her peers and its a never ending saga. Being short-staffed to dangerous levels, overwhelmed and asked to perform mission impossible is never going to be something they accept. It's always the nurse and shame on him/her! Eventually, low self esteem and confidence take a nose dive and people leave the area, or nursing. I have seen it many times in my career.
  9. by   Spaciousness
    Great story. You used the terms "Task" as opposed to "thought" orientation. I like the term "process." Process, process, process! It's another way of referring to "critical Thinking." What comes to mind is a book written by a physician called, "The Check List Manifesto" by Atul Gawande--an excellent book about process or critical thinking. One of his points is that healthcare, medicine, and associated technology has become so complex with so much new information and level of complexity that no one can stay on top of it all. In order to eliminate (or at least significantly reduce) error, all of us should engage in the process of the checklist--even with tasks that we think we have mastered. For example, even if you have worked with the same patient for 12 hour shifts, 3 days in a row you still ask them to state their full name and check what they tell you against their wrist band and the room # (and associated name) and another source as part of the "right patient" portion of the "5 rights." Even if you check the bar code on their wrist band against the Computer on Wheels (COW). Some things may seem very very obvious, so much so, that we throw the check list out and go right into the task (e.g. "I obviously know who this patient is and I know what drug they take at this time so I am going to skip the process of asking him or her to tell me their name and check their band and instead I can go right into the task of giving the med"). Whether you are a pilot prior to take off, or a surgeon get ready to cut, or a nurse about to give a med, ALWAYS go through your check list no matter how obvious things may (or may not) seem. We shouldn't worry about other's possible judgment of us for engaging in this process.
  10. by   JudiRNNJPAWA
    I remember making a med error, also as a new nurse. Gave a med IV instead of IM. IM was not an option. We gave "everything" IV in ICU & I didn't realize this med would never be given IV. No apparent damage was done but I force myself to remember that every time I give a medication.
  11. by   Nmbeck
    What ever happened to the two-nurse dose check for insulin? That used to be standard practice everywhere, but I hear many hospitals have stopped. If this poor young lady had been protected by that, or at least had known it used to be STANDARD for a second nurse to double check insulin doses, she would've thought of it as NORMAL or correct to ask for a double check on insulin instead of feeling embarrassed to ask! I mean a second nurse should literally LOOK at the order, the filled syringe to check units, verify the vial (correct type of insulin and expiration date), and co-sign. (Diabetic patients with good management at home are good resources, but I haven't met one yet in the acute care setting who a)has good control and b)could give me accurate info about their insulin regimen! Margo's patient is a case in point.)

    My heart goes out to Margo, and I'm so grateful her hospital was supportive by helping her recover and stay in nursing. There are many take aways here. Thank you!
  12. by   peacockblue
    I made a significant med error once. There was no harm to the patient but the fear and shame I felt not following all my "rights" was terrible. I owned it and was not disciplined but I will never forget.
  13. by   TaeRN
    Thank you for the article. Medication errors can happen at anytime whether your new nurse or experienced nurse.
    I just started traveling as a nurse and I had a charge nurse said to me that I asked too many question. I told her I'm going to be a safe nurse so if I don't know or if I'm not sure I ask questions. I would much rather somebody think I don't know that much then to make an error.
    Great article!
  14. by   billswife
    Can anyone tell me why the Root Cause Analysis might be changed to exclude the nurse who made the error? It seems counterintuitive to me. What don't I understand?

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