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."
