The Wrong Dose - A True Story of Medication Error

[SafetyNurse1968]

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."

[dec2007]

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?

[determined25]

Excellent article/interview. Don't be afraid to ask for help. That's my biggest fear.

[JulieRN60]

When I was a brand new nurse ( a thousand years ago), an order was written to give a pt Lasix 40mg/4ml, iv push. The nurse giving me report at shift change failed to mention she had done this and had not signed off the MAR. SOOOOO, that being said, I read the MAR, verified the order in the chart, made sure we had the med, and gave it slow push....,and hour or so later we were at a mandatory staff meeting when the charge nurse burst through the door, shouting about ,"Why did you give the lasix to Mrs. X?" I told her I had verified everything, the previous nurse had not mentioned giving it, nor was the MAR signed. The CN continued to screech loudly enough for the North Koreans to hear about how I had given this pt "too much medication," in front of my peers, other patients and their family members...I immediately went and called the physician and explained my error, and he said (I will never forget this)," The extra Lasix will probably keep her alive another week, her heart is on complete failure, and she refuses to do anything more about it." He wrote another order covering the extra lasix, thanked me for calling and hung up. I reported all of this to the CN (who informed me that she had written me up and was suggesting the DON call the Board of Nursing) and the DON. I was near tears at this thought, but I faithfully charted every word stated by the physician, his verbal order, and the fact that I had checked on the patient every 5 minutes for 60 minutes without any adverse effect, VS stable, etc. The DON shut down the CN, stating that she had acted very inappropriately by calling me out in front of the entire, staff, patients and their families, she tore up the write-up, thanked me for calling the doctor and spoke with the nurse I relieved, who was horrified to learn she had forgotten to sign off the MAR, or tell me she had given the med, she used the fact that she was moving soon and had a "lot on her mind" as her reasoning. Needless to say I watched that patient like a hawk for the next two days, the third day I came in to relieve the nurse (different) we were doing walking rounds and we cam to Pt x's room, she was sitting up in a chair with her eyes closed. The other nurse said, "oh look, she's sleeping." I looked, and said," I don't think so," as I reached to touch her hand which was cold, no pulse, etc etc....eek. so the drama ended, but I NEVER FORGOT THE ERROR, and have used the "question, question, question", up to and including calling nurses at home to clarify any medication questions, from that time forward.

[Howej1]

I have had a near miss with Insulin as well working in the Elergency Department. I also had another med error in that same department. I was a new nurse and had an EXCELLENT preceptor. I learned from both but was never involved in a root cause analysis and was made to feel ashamed for the error.

The insulin near miss was on an extremely overweight and uncontrolled diabetic. I believe the patients blood sugar was in the 3-400s. I had started an IV and was giving saline. The PA ordered regular insulin 90 units IV. I thought "No way!" So I questioned the PA reading the order out loud "you want the patient to have 90 units nine zero via IV, of regular insulin??" The PA said yes. I took the chart (was paper then) and went to sit down. I thought for a minute and still couldn't believe it. It was 10x the highest IV dose I had seen. I went back to the PA thinking maybe this was a

Drop over several hours. I asked again," you want me to give 90 units of regular insulin IV push to the patient? Are you sure?" The PA again verified it. The patient was not on a monitor and was in an area where rooms were separated only by curtains. All I could think of was coding this large patient where all could add. I knew I couldn't give the insulin but was unsure how to proceed. My preceptor was gone that night so I went to the physician in charge and said, "I do not think this order is right, would you mind to verify it? It seems like too much to give IV to me." The doctor looked and immediately said that is WAY too much, it should be 9(nine) units!! Good catch though. Thanks for coming to me. He spoke with the PA and it turned out ok.

The other incident occurred when I had 2 patients come in at the same time with chest pain. They had similar names and one was in his 50s and the other in his 20s. Back then we had protocols where we could give aspirin and nitro to chest pain patients with appropriate vitals. I took the paper chart in which the doc had ordered nitro x3 into the 20 something guy's room and gave him a dose. I then realized the order was for the 50 year old patient. Had the doc not seen them already, I would have been covered by the protocol. But this doc was very nervous anyway and got upset, chewed me out and made me write an incident report. I didn't get in further trouble but was terrified after that.=

[CFitzRN, ADN]

The kinds of nurses who immediately shame another nurse, yell, make a huge deal out of a mistake, are the nurses I would fear the most. They are prideful yet insecure, and they have a clear need to lift themselves up by tearing another nurse down. I experienced this as a new nurse in Labor & Delivery. I had a good preceptor (tough though) but other nurses tore me down for every tiny thing, for asking questions, for not knowing every answer. I was a new nurse! I didn't know everything (neither did they, but they liked to act like they did). I needed experience and support, not constant negative criticism. Needless to say, I didn't last long in the hospital. God was good to me and I found a series of good (better) jobs, more suited to my personality and without all the shrews and harpies who thrive on horizontal violence. I just don't get that mindset at.all. We are all in this together - let's support and help each other and make the workplace a BETTER place to be, not hell on earth.

[SafetyNurse1968, ADN, BSN, MSN, PhD]

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.

SO true - thank you for commenting and sharing.

[SafetyNurse1968, ADN, BSN, MSN, PhD]

I have had a near miss with Insulin as well working in the Elergency Department. I also had another med error in that same department. I was a new nurse and had an EXCELLENT preceptor. I learned from both but was never involved in a root cause analysis and was made to feel ashamed for the error.

The insulin near miss was on an extremely overweight and uncontrolled diabetic. I believe the patients blood sugar was in the 3-400s. I had started an IV and was giving saline. The PA ordered regular insulin 90 units IV. I thought "No way!" So I questioned the PA reading the order out loud "you want the patient to have 90 units nine zero via IV, of regular insulin??" The PA said yes. I took the chart (was paper then) and went to sit down. I thought for a minute and still couldn't believe it. It was 10x the highest IV dose I had seen. I went back to the PA thinking maybe this was a

Drop over several hours. I asked again," you want me to give 90 units of regular insulin IV push to the patient? Are you sure?" The PA again verified it. The patient was not on a monitor and was in an area where rooms were separated only by curtains. All I could think of was coding this large patient where all could add. I knew I couldn't give the insulin but was unsure how to proceed. My preceptor was gone that night so I went to the physician in charge and said, "I do not think this order is right, would you mind to verify it? It seems like too much to give IV to me." The doctor looked and immediately said that is WAY too much, it should be 9(nine) units!! Good catch though. Thanks for coming to me. He spoke with the PA and it turned out ok.

The other incident occurred when I had 2 patients come in at the same time with chest pain. They had similar names and one was in his 50s and the other in his 20s. Back then we had protocols where we could give aspirin and nitro to chest pain patients with appropriate vitals. I took the paper chart in which the doc had ordered nitro x3 into the 20 something guy's room and gave him a dose. I then realized the order was for the 50 year old patient. Had the doc not seen them already, I would have been covered by the protocol. But this doc was very nervous anyway and got upset, chewed me out and made me write an incident report. I didn't get in further trouble but was terrified after that.=

I am glad it turned out the way it did. Did the hospital offer you any support, and/or did you seek out any for yourself?

[Guest219794]

Great article. Thank you.

I believe that errors happen at a much higher rate than is commonly believed.

There are countless errors that never get reviewed.

• Nurse makes a mistake and never reports it from shame or fear.
  
• 
  
• An error that causes no harm. I just gave Mrs Smith's daily meds to Mrs Jones and visa versa, and they both made it through the day.
  
• 
  
• An error that occurs, but has no apparent, obvious, harm that can be traced back to the nurse. For example- any medicine given to a dying patient. If I make an error, and the patient dies as a result, how would I, or anybody, know the error occurred?
  

I believe we have all made mistakes we know nothing about.

[BlinkyPinky]

Wow! Insulin is so potentially harmful , that I have long- considered it a very dangerous medication. Almost as bad as K+. Given incorrectly.

I'm glad it turned out alright for patient

[SafetyNurse1968, ADN, BSN, MSN, PhD]

Great article. Thank you.

I believe that errors happen at a much higher rate than is commonly believed.

There are countless errors that never get reviewed.

• Nurse makes a mistake and never reports it from shame or fear.
  
• 
  
• An error that causes no harm. I just gave Mrs Smith's daily meds to Mrs Jones and visa versa, and they both made it through the day.
  
• 
  
• An error that occurs, but has no apparent, obvious, harm that can be traced back to the nurse. For example- any medicine given to a dying patient. If I make an error, and the patient dies as a result, how would I, or anybody, know the error occurred?
  

I believe we have all made mistakes we know nothing about.

Thank you for reading - I so appreciate it when folks read and comment. Sharing and open discussion around this issue will help prevent errors - I firmly believe that.

[elkpark]

While not saying this to shame or criticize the nurse in the article, I would question her statements that her nursing school focused on teaching "tasks," not "thinking." That was certainly not the case at the nursing school I attended, and I hope it's not the practice in many schools.

[SafetyNurse1968, ADN, BSN, MSN, PhD]

While not saying this to shame or criticize the nurse in the article, I would question her statements that her nursing school focused on teaching "tasks," not "thinking." That was certainly not the case at the nursing school I attended, and I hope it's not the practice in many schools.

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.