Possible BIG insulin error (patient okay)- Tips for risk-reducing methods?

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I will try to keep this short. So it was the start of this evening shift, I was preparing my meds and when I got to the Insuman Basal for one patient, a sudden dreadful feeling appeared as I felt that "this isn't the pen I gave this dose with last time". The other pen in the patient bin was, yes, Lispro...

MASSIVE black hole opens up in my stomach. The last time I had worked with that patient group and given that insulin was a couple of evenings earlier. I remember giving the patient insulin at 8pm while the patient was eating a night snack, and then giving the patient night medicine two hours later. Nothing appeared wrong with the patient then. At 7 am the day after I get back for my day shift, and nothing appeared weird with the patient from the night shift, other than that "the patient had slept heavily and had been wet", nothing out of the ordinary for this patient.. The patient showed no signs of being unwell in the morning after or the rest of the day either. As the patient has been stabile in the blood glucose levels, unless something seems amiss we don't follow it regularly anymore (which isn't uncommon here). I did however check it the evening when I realized my possible mistake and it was okay, but of course that was several days afterwards..

Of course I feel like *** for the rest of my evening shift. Slept like *** that night, and the first thing I do in the day shift is go to talk to my boss and the doctor. As I really have no factual basis for any error other than my gut feeling they're skeptical, and as neither me, my colleague in the evening shift or the night shift nurses saw any signs of hypoglycemia with the patient which should have appeared rather quickly after such a large dose of Lispro (we're talking 3x the usual dose for the patient), they told me that they logically thought it's unlikely that I mixed them up. They probably saw how enormously shakingly I was and that I had realized the full scope of my possible mistake and learnt from it, so they told me that the important part was that the patient was okay, that I had told them asap and didn't try to hide it, and that I should try to move on.

So yeah, here I am now. I know that logically we probably should have noticed something amiss with the patient, and that my memory could be playing tricks on me, but my gut still tells me that I could have given the wrong insulin, and that maybe the deep sleeping was that the patient was actually hypo... I know that giving too much insulin/wrong kind is one of the most dangerous things you could do as a nurse. I'm just so happy that the patient is okay, I don't think I could go on if I would seriously harm a patient like that. I'm never ever giving any insulin without seriously cross-checking it a million times. I'm probably never gonna find out whether I actually did wrong or not, but to ever move forward I feel like I need to use this in a positive way, by preventing future mistakes from happening. Double-checks and bar codes is unfortunately unheard of here. All kinds of tips and suggestions that I could raise is welcome!

Specializes in retired LTC.

I am NOT negating anything you said. You'll learn that when you get that funny 'gut' feeling or that 'ESP' twinge, you're prob right.

But I'm thinking, even if your pt had been 'hypoglycemic' sleeping, wouldn't she NOT have continued to drop thruout the night? So that when staff tried to arouse her in the morning for breakfast, she'd have been unarousable, like as in reeeeeally unresponsive?

So for your future, you learned a lesson about being SUPER DUPER careful re insulins. That's all you can do - learn and move on.

Always LISTEN to that funny little inside voice - it's trying to tell you something. I learned to listen and it did save me from errors and critical pt care issues.

Funny thing - that little voice seemed to be most vocal with diabetics!

Oh, and welcome to AN.

47 minutes ago, amoLucia said:

I am NOT negating anything you said. You'll learn that when you get that funny 'gut' feeling or that 'ESP' twinge, you're prob right.

But I'm thinking, even if your pt had been 'hypoglycemic' sleeping, wouldn't she NOT have continued to drop thruout the night? So that when staff tried to arouse her in the morning for breakfast, she'd have been unarousable, like as in reeeeeally unresponsive?

So for your future, you learned a lesson about being SUPER DUPER careful re insulins. That's all you can do - learn and move on.

Always LISTEN to that funny little inside voice - it's trying to tell you something. I learned to listen and it did save me from errors and critical pt care issues.

Funny thing - that little voice seemed to be most vocal with diabetics!

Oh, and welcome to AN.

Yeah, probably.. I'll have to say that I haven't had much experience with hypoglycemic patients yet, but AFAIK Lispro onsets in 15 mins, peaks in 30-90 mins and goes out after 5 hours.. So maybe the bg levels had enough time to go up after 5 hours when the Lispro went out so the patient was back to normal when we were back for our day shift.. Or maybe that's not how it works..

Anyhow, yeah the funny/weird gut feeling is mostly right, but I can actually think of a few times at work when it's been clearly wrong for me too, so who knows.. 

Yeah, I guess I should count myself really lucky. Whatever the truth is, the patient is okay and now I got this realitycheck that will (hopefully) stop future errors and make me a better nurse!

One annoying thing here is that for some reason doctors seems to like to put the patients on Insulin that we don't have, like NovoRapid instead of Lispro and Insulatard instread of Insuman Basal, and those doesn't show up as interchangeable on the computer so you have to go someplace else to see which ones that are. My first action is gonna be to nag to all my future doctors to make sure that while the patient is here, they should be on the same kind of insulins that we have in stock. All the different names for such a high-risk drug feel like another risk-factor for a mixup.. 

Specializes in retired LTC.

Docs all get the early sales pitch from pharmaceutical reps re 'their' products as the best-est new med on the market. So the Docs order the new meds.

Everything from insulins to cardiac to allergy to inhalers, etc. That's not to say that the new meds may NOT be the newest best thing, but availability  is another thing. If you think you're having issues in hosp, consider the nightmare in NH/LTC.

And don't even think if about discharging pts to home these pts on the newest meds. Insurances will be quick to deny payment for the med not being on 'formulary'. Then the pts/families go wild crazy when they have to pay out-of-pocket and/or high deductibles/copays. They just don't get it.

So much for the state of health care and Big Pharm.

Specializes in New Critical care NP, Critical care, Med-surg, LTC.

You may or may not be correct about a mistake being made, but as you pointed out, no harm came to the patient. You will NEVER make that mistake again, so it's all a learning experience and you will be sure to double check the insulin before administering in the future. We all know that sinking feeling in the pit of your stomach. It stinks, but it means you care about your job and doing the right thing. Not much in the way of advice from me. Just give yourself a break and move on. Take care. 

Specializes in Education, Informatics, Patient Safety.

My heart goes out to you! I've made three med errors in my life as a nurse (20 years) and each one is as clear as the day I did it and one of them was with insulin. I'm a patient safety expert, so I can tell you that mistakes are incredibly common - it's just that most nurses don't talk about them out of shame and fear of consequences so be very proud of your integrity and try to forgive yourself - research shows that most nurses won't get through a career without making at least one mistake (we are human!)

You asked how to prevent another error and I have a few tips for you. I would recommend talking to the pharmacist where you work - you have identified an error that will likely happen again - having two insulin pens in the same drawer is a recipe for disaster - though you will be extra careful, some other nurse is open to making the same error. Work out a plan with the pharmacist and the charge nurse to change policy around keeping the same delivery method of insulin (I hope that makes sense) in the same drawer or at the very least label one of the pens with bright orange tape and a safety label or message saying "WARNING - DOUBLE CHECK THIS MEDICATION"  You didn't mention it, but be sure to go through a double check with another nurse with all high risk meds like insulin and heparin - don't just swing by and show them the pen - actually document which nurse you checked with.

The most important thing you can do is advocate for medication safety at a systems level - this means asking for Root Cause Analysis of medication errors so your organization can develop strategies to protect nurses and patients from future medication errors. Very few errors are committed because a nurse is negligent - most of them are due to communication, fatigue and being pressed for time - these are all things your organization can work to improve.

You can subscribe to my blog here on AN (I'm not selling anything here - just trying to reduce harm to patients and nurses - the emotional toll of making an error contributes to nurse burnout). Here's one of my blogs about patient safety strategies at an organizational level (there are others that discuss med errors that may help you feel better):

Try to be gentle with yourself - you are a hero for reporting the error - so many nurses don't report. THANK YOU.

Specializes in ER, Tele, Education.

Medication safety is one of our most important functions in nursing. Many of us have been where you are. We second guess ourselves when things don't seem quite right. It takes time to build confidence and trust in our skills to do what we do well.

That being said, rely on the proven methods of med administration. 5 or 6 or 10 rights (depending on the reference), 3 checks, 2 nurse checks on critical meds such as insulin and heparin, minimize distractions, look up your meds ahead of time. Joint Commission has good info on this as well as the ISMP (Institute for Safe Medication Practices) https://www.ismp.org/ 

You seem to be very intelligent. Rely on your critical thinking skills. Besides the diabetes, was anything else going on with your patient(s)? Rarely do our patients have only one medical problem. Don't look for zebras, just a reason for your patient to have those symptoms.

Specializes in Psych, Corrections, Med-Surg, Ambulatory.

Just like it's possible to make an error without realizing it, sometimes something seems like an error when it isn't.

When I was new to med-surg and PCA machines, I once had to program it for hydromorphone.  The patient was very painful on arriving from PACU so I gave the whole bolus of 1 mg.  As it was infusing, I thought, wait a minute.  Hydromorphone is in 10ths of milligrams.  I pushed the stop button on the PCA and went to find the charge nurse.  She double-checked the order with me, yes it was 1 mg, yes it is appropriate for a hydromorphone bolus.  I took a breath and restarted the pump so the poor patient could get some relief.

While I had been talking to the charge nurse, a coworker overheard me and brushed by, dropping something in my pocket.  After I was reassured and gotten the situation squared away, I checked to see what she had given me.  It was a vial of narcan and a syringe.  I didn't need it of course, but it was nice to know someone had my back.

So sometimes something can look wrong, when it's right.  And there is no feeling like that sudden gut clench.

Specializes in Public Health, TB.

That's too bad about barcodes, this may be one of the few things I like about electronic medical records. 

Is there another way to flag the pens? A bit of colorful tape with basal or fast written on it? How about leading a short inservice at your next staff meeting? Create a colorful poster with the different insulins to hang in your med room? 

Here's a doozy of an insulin dose: ICU used to love transferring open heart patients at shift change, by loading them into a wheelchair, taking the IVs off the pump and placing in the patient's lap, and having the NAC wheel the patient to our unit. They did this at shift change so a nurse could do her whole shift without getting low census, and they refused to let "their" pumps leave the unit. So I am just starting my shift as charge, and the nurse who just received the patient realized an IV bag labeled "100 units regular insulin" is empty. And had just been hung 15 minutes prior to transfer. Well, snap. 

Patient did fine, nurse handled it beautifully, and I had a convo with the ICU charge, who pretty much figured our staff was at fault. Oh, well. 

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