The Wrong Dose - A True Story of Medication Error

An interview with Margo, an oncology nurse, who talked about the night she gave a patient too much insulin, and he coded. 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. Nurses Safety Article

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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.

SN: 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.

SN: 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."

It sounds like you had a very different experience. Unfortunately, from what I have seen as a nursing instructor at many different schools of nursing the practice in many schools of nursing is to be task oriented. There are as many different ways to teach nursing as there are ways to be a nurse. I am so glad you had a good experience. Please let us know where you went! I would love to have a place to recommend to folks.

I went to a hospital-based diploma school that is no longer in operation. I got an excellent education in nursing, and it was certainly not "task oriented." The ADN and BSN programs in which I have taught in the past were also not "task oriented" to the exclusion of higher level knowledge and critical thinking.

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When I was a new nurse, my very first day on the floor nonetheless, I had a patient who had a colon resection having severe pain that was uncontrolled with his current regimen.

I asked the resident for a breakthrough dose of IV dilaudid and he ordered it- a whole 25mL/25mg PCA syringe as a one time dose.

It was the resident's first day as well, but that is no excuse. He was able to order it without PCA settings (bolus dose, lockout) literally as just the whole 25mg of IV dilaudid as a one time dose-- and pharmacy verified it. I only realized the error when I went to pull this medication and realized the size of the syringe, which also read: FOR PCA USE ONLY.

Thankfully, I did not give this medication and the error was corrected. What a reminder that as RNs we truly ARE the LAST line of defense for the patient when it comes to med errors. You are not alone. :)

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You're very lucky, but I think the way your error was handled is the correct way.

Sadly, many nurses are severely disciplined or even terminated for even minor medication errors. This punitive mentality can only lead to cover-ups and harm to patients due to non-reporting.

Thank you for being an advocate... but there's a long way to go for the profession as a whole.

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Specializes in Hospice, corrections, psychiatry, rehab, LTC.
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!

I had much rather have a nurse ask questions about something that he or she is unsure about than to blindly charge ahead and do the wrong thing. I never mind questions.

Margo was indeed fortunate to work for an employer who is so supportive, and so cognizant of the fact that many errors are facilitated by the system in which they occur. Many employers would have just terminated her, perhaps reported her to the state board of nursing, and left her emotional and professional scars to become someone else's problem.

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Such a great article!

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Specializes in NICU/Neonatal transport.

I had an RX near miss - we had an order set for extravasation meds, and they had switched the order they were in before. I was discussing another patient whose condition was deteriorating when an RN notified me that an IV with TPN had infiltrated and could she get an order of hyaluronidase. I was multitasking and relied on the old order and clicked the wrong box: phentolamine instead. (what we use for dopamine extravasation) The patient wasn't on dopamine, pressors or any med that would be treated with that. The computer didn't flash an alert when I ordered it (that I ordered the treatment for a med the patient wasn't on) the pharmacist verified it and sent it (again, despite the fact the patient wasn't on any meds that it would be appropriate to treat.) The RN got it, and though it matched the order, came back to me and said "don't we usually use hyaluronidase?"

Whoa nelly! Great catch by the RN. Obviously I cancelled the incorrect order, corrected it, and then wrote an incident report for the near-miss. And I don't multitask, even on "easy" orders anymore. And teach new students that same caution - don't rely on "easy" orders that you think you could be safe to do while multitasking. Even the little ones, take the time to give it your full attention. I've never had the nightmare administration that others describe. I sat down with my manager to discuss the near miss, and to see if we could get an alert if we order the antidote to something the patient isn't receiving. And reminder to pharmacy too. I definitely screwed up, and I'm very glad the RN caught it before it reached the patient, but there were a couple of misses down the line that should have caught it too.

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Specializes in Oncology, Home Health, Patient Safety.
5 hours ago, LilPeanut said:

I had an RX near miss - we had an order set for extravasation meds, and they had switched the order they were in before. I was discussing another patient whose condition was deteriorating when an RN notified me that an IV with TPN had infiltrated and could she get an order of hyaluronidase. I was multitasking and relied on the old order and clicked the wrong box: phentolamine instead. (what we use for dopamine extravasation) The patient wasn't on dopamine, pressors or any med that would be treated with that. The computer didn't flash an alert when I ordered it (that I ordered the treatment for a med the patient wasn't on) the pharmacist verified it and sent it (again, despite the fact the patient wasn't on any meds that it would be appropriate to treat.) The RN got it, and though it matched the order, came back to me and said "don't we usually use hyaluronidase?"

Whoa nelly! Great catch by the RN. Obviously I cancelled the incorrect order, corrected it, and then wrote an incident report for the near-miss. And I don't multitask, even on "easy" orders anymore. And teach new students that same caution - don't rely on "easy" orders that you think you could be safe to do while multitasking. Even the little ones, take the time to give it your full attention. I've never had the nightmare administration that others describe. I sat down with my manager to discuss the near miss, and to see if we could get an alert if we order the antidote to something the patient isn't receiving. And reminder to pharmacy too. I definitely screwed up, and I'm very glad the RN caught it before it reached the patient, but there were a couple of misses down the line that should have caught it too.

THANK YOU for doing an incident report on this - you've prevented some harm down the road. I so appreciate the share.

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Specializes in NICU/Neonatal transport.
19 minutes ago, SafetyNurse1968 said:

THANK YOU for doing an incident report on this - you've prevented some harm down the road. I so appreciate the share.

I write incident reports always, and encourage RNs to do them too. Too many view it as being "written up", and some even try and use it as a way to "write someone up", but really, that's not what it's there for.

Most recently, we did an incident report for an OB who failed to check the mother for HepB during pregnancy. It's state law to check here. None of the OBs who admitted her noticed she hadn't had it checked this pregnancy either. Now, it's not to get the OBs in trouble per se, but as neos, we often have a hard time finding the important infectious prenatal labs (that they should really care about too) and if they know the status of them all, they should list them, and if they don't - well, they should send them out. We had to give the HepB vaccine by 12 hours of life because of no status on mom.

That's not truly harm to the patient, but it's a huge systematic issue. If they don't have a process for documenting/listing that, one needs to be developed, and if we wrote an incident report every time it happened, they would see it is a big issue. People just have to stop looking at it like a "tattling" system.

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Specializes in MICU/CCU, SD, home health, neo, travel.

I made a terrible error when I was a fairly new nurse. It was partly because I misread a doctor's handwriting. He had written an order for 10 mg. of Vistaril to be given to a severely vomiting child, but to this day I will swear it looked like 100 mg. At that small hospital the pharmacy was not open at night and the supervisor had to get the medication. She looked at the order also and signed off with me and went and got the medication. The child stopped vomiting and went to sleep and I went on about my duties (I was the only nurse on the unit because that was how it was staffed.) The next day when I came in to work I was hauled in to the DON's office and interrogated. We all looked at the order and I was told I "should have known" the medication. Yes, that was my fault, I should have looked it up. But I got the blame and the nursing supervisor, who had looked at the order and signed off with me, apparently got off scot free, while I got written up and was transferred off that unit permanently (which was a relief to me, really).

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Specializes in Oncology, Home Health, Patient Safety.
41 minutes ago, CeciBean said:

I made a terrible error when I was a fairly new nurse. It was partly because I misread a doctor's handwriting. He had written an order for 10 mg. of Vistaril to be given to a severely vomiting child, but to this day I will swear it looked like 100 mg. At that small hospital the pharmacy was not open at night and the supervisor had to get the medication. She looked at the order also and signed off with me and went and got the medication. The child stopped vomiting and went to sleep and I went on about my duties (I was the only nurse on the unit because that was how it was staffed.) The next day when I came in to work I was hauled in to the DON's office and interrogated. We all looked at the order and I was told I "should have known" the medication. Yes, that was my fault, I should have looked it up. But I got the blame and the nursing supervisor, who had looked at the order and signed off with me, apparently got off scot free, while I got written up and was transferred off that unit permanently (which was a relief to me, really).

So sorry this happened to you. It sounds like an honest mistake (so many of our errors are exactly that - honest mistakes.) It seems like having a pharmacist on staff 24/7 would have prevented that from happening. I hope the child was okay. It sounds like you have been able to move forward and are in the process of letting it go - it's just so hard, we hold ourselves to unattainably high standards! Thanks for sharing.

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Specializes in retire-numerous.

Agree with Nmbeck--what happened to double checking certain meds--you just did it for safety reasons

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Hello, great article! I did not see the link to the podcast for this article. Can you please place the link for me to hear the podcast. Thanks so much!

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