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VENT! They could've KILLED somebody!

Posted

Specializes in geri.

Let me first say that I have been a nurse for less than 6 months. But this made me really nervous, and I wondered what they were thinking!

John and Jane are both nurses on my unit. We do team nursing - Jane was passing meds for half of the unit while John was performing patient care for the same patients. One patient has an elevated blood sugar. Jane took blood sugars herself and followed policy; his blood sugar was rechecked and the accountable RN (me) was notfied. I notified the doc, doc said use sliding scale per order.

I tell Jane to give Mr. XX his 8 units of sliding scale, docs orders. She says okay. A few minutes later, I found John in the med room (using Jane's key and Jane's computer) drawing up insulin. He asks me a question about the computer, so I go to look over his shoulder. On the desk I see an insulin syringe with 10 units drawn up. On the computer screen, i see he has typed "Verified with Jane Doe, LPN." (meaning he as verified the insulin with her - patient, type, amount, etc.) I ask him what he's doing in the med room, anyway. He tells me Jane is at lunch and asked him to give Mr. "YY" his insulin. But Mr. YY's blood sugar was normal. He tells me that he knew that, but had to fix it in the computer. HE HAD NOT GIVEN THE INSULIN YET, thank god. He says no big deal, Jane told him Mr. YY but she meant Mr. XX. So he was going to go give Mr. XX the insulin now, not to worry. I had to tell him to verify the order again, because Mr. XX should receive 8 units, not 10!

Long story short, he came really close to giving the WRONG patient 10 units of regular insulin.

I know now the difference between nursing school and the real world. But I would never give insulin (ESPECIALLY 10 units) to a patient when I was not the med nurse nor had I personally checked his blood sugar or looked up lab in the computer to verify that the blood sugar was indeed that elevated.

What do you think? Someone walks up to you and says, "I just checked mr. smith's blood sugar and it's 402, could you give him 10 units of insulin for me?," would you do it?

I say she shouldn't have asked him and he shouldn't have agreed.

TheCommuter, BSN, RN

Specializes in Case mgmt., rehab, (CRRN), LTC & psych. Has 15 years experience.

If I obtained a FSBS result which necessitated the administration of sliding scale insulin coverage per physician's order, it would have only taken a few more minutes for me to personally give the injection.

I would not have gone to lunch until I had personally given the insulin.

aloevera

Specializes in telemetry, med-surg, home health, psych.

I don't even give a pill to someone that I didn't get myself....maybe I am just too un-trusting, but it is my license on the line and if there is a mistake to be made it will be ME doing it, not me taking the blame for someone else's mistake !!

what are these people thinking ??

helper T cell

Has 7 years experience.

when we give insulin at our facility it is a two nurse ck. Second nurse must verify and sign MAR along side nurse that draws it up. We leave needle in vial so 2nd nurse can see type of insulin as well. Wow that would have really scared me. Were you able to debrief with the two nurses? Maybe Jane will think twice before she does that again. Glad no harm was done.

racing-mom4, BSN, RN

Specializes in ICU/ER.

We dont have 2 nurses double check insulin, but we should...I agree I would never give anyone anything unless I assessed and got it myself out of the pyxsis.

I was once floated out to the Med Surge floor and a floor nurse handed me a syringe and asked me to go give it to the pt in 217. I told her no I dont give anyone anything unless I draw it myself and she copped an attitude with me and asked if I didnt trust her. I explained of course I trusted her, I just dont do that, nor would I ask anyone else to do that, she bickered back and forth for about 5min, then I told her in the 5 min we have been discussing this either I could have looked at the Mars/the pt and drawn it up myself or she could have admin it herself.

FYI she is one of "those" nurses that work harder to not work than they actually work....cant stand that type.

if someone reported a bs to me, i'd recheck it myself.

it's the only way i could decide to give insulin or not, by my findings and no one else's.

leslie

lolagurl

Specializes in dementia. Has 7 years experience.

So how did John react when you told him he had the wrong patient and the wrong dosage?

During clinical we did an observation in ICU and the nurse that I was following asked me to give our pt. the oral meds that she had pulled and checked against the MAR. I said I would but I'd like to check them for myself, so when I did I found that there was an extra dosage of Amiodarone included in what she had handed me. I gave her back the meds and told her about the extra pill. She said oh I thought the order read two Amiodarone. It read one ...mg Amiodarone twice daily. Can you imagine what could have happened if I would have given those meds without checking them first? It would have been a good thing the patient was already in ICU!

papergirlRN

Specializes in geri.

Thanks to everyone for the replies. . . .

I did speak briefly with Jane and John about it. They were very flippant, couldn't have cared less, no big deal. I think they think I over reacted.

BUT- I told them that since I was so new in the charge role that they would just have to follow the rules on the days i was in charge and that they could do whatever they wanted to when somebody else is in charge; they couldn't kill anyone on my shift because it causes too much paperwork. HAHA. They seemed alright with that. Who knows? Only time will tell.

PiPhi2004

Specializes in Trauma ICU, Surgical ICU, Medical ICU.

Killed someone? now really? I agree that the practice was indeed wrong but at least it was caught.

Spoiled1, MSN, RN

Specializes in Step-down ICU.

As the title of the post indicates, they COULD have killed somebody. Luckily it was caught. You don't play with Insulin!

As a point to consider...I don't even like when the graveyard shift nurses do the fingersticks and then cover according to the sliding scale, nor do I like it when they do the fingersticks (at about 6 or 6:30 am) and then I have to cover the bloodsugar. I tell most of them to just leave it until I start at 7 am and I will check the sugar and cover per MARS. That way I know exactly what the sugar was and I make myself responsible for covering it.

As a point to consider...I don't even like when the graveyard shift nurses do the fingersticks and then cover according to the sliding scale, nor do I like it when they do the fingersticks (at about 6 or 6:30 am) and then I have to cover the bloodsugar. I tell most of them to just leave it until I start at 7 am and I will check the sugar and cover per MARS. That way I know exactly what the sugar was and I make myself responsible for covering it.

I don't like checking BS or giving insulin before breakfast either. Too many things can happen. However, I am informed, "this is the way we do things here." :banghead:

RedhairedNurse, BSN, RN

Specializes in Med Surg, Ortho.

In the case of having two nurses sign off on insulin. In most cases, I just see nurses scan each other's badge or something....I've never seen the "other" nurse look or verify the dose of insulin.

I'm going to want the nurse to show me her dose if I'm the second nurse signing off her insulin. I'm sure there going to consider me biotchy, but hey, it's my license. Do any other nurses here ok the second dose without looking at it? Am I over reacting to this practice?

aloevera

Specializes in telemetry, med-surg, home health, psych.

the med nurse draws it up, shows it to me, and I OK it....that is how we do it where I work....I wouldn't verify anything that I didn't look at.....

we all can make a mistake, that is why 2 check it.....:D

RNcDreams

Specializes in Tele, ED/Pediatrics, CCU/MICU. Has 4 years experience.

In my unit, if I have to give insulin, it goes like this:

I obtain the vial ,draw it up, and then take it to RN # 2 and place it in front of her.

She then tells me the kind of insulin in the vial and how many units I have of it, as I simultaneous re-check the order.

It works!

As the title of the post indicates, they COULD have killed somebody. Luckily it was caught. You don't play with Insulin!

ITA Giving insulin-especially 10 units- to someone with normal blood sugar is scary. For those nurses not to even think this was a problem is even scarier.

helper T cell

Has 7 years experience.

On our unit it is a medication error if you do not have your insulin dose verified and signed. Common courtesy to other nurses have everything drawn up, mars available for them to ck and sign before you call them over to do the ck. A very nice nurse pointed this out to me early on. Also when you need to waste a narcotic. Have it all ready to go. Also it seems obvious to me now, but leave syringe in vial. I wasn't doing this at first and again this was pointed out to me lucily in a nice way.

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