potentially lethal error

recently i have found lots of errors at work. sometimes they are minor. tums from the day before are still left at the bedside. an IV medication is hung an hour late. somebody is supposed to be NPO (nothing by mouth), but they eat breakfast. these errors can delay treatment or put a hiccough in the day. but unfortunately, i have found some larger errors lately too. yesterday was a BIG one. a potentially LETHAL error. made by a new nurse. and i can't help but be dumbfounded as to how much responsibility we have as nurses and how much potential we have to harm. i also can't get over the fact that this nurse passed nursing school, the NCLEX (our certification test), and 6 weeks of orientation on our unit.

during shift report, the off-going nurse was telling me about her night with nurse patient. i was logged into the computer, assessing her labs. when i saw a critically low blood sugar at midnight, i inquired. the nurse slowly revealed what had happened. not until minutes prior had she realized her mistake. here is what happened:

at 1926 on friday night, before i left, i checked nurse patient's blood sugar. it was 276. this is high. the night nurse said she would notify the doctor and get some insulin orders. so, i left. assuming all would be well. LESSON ONE: don't assume.

the night nurse was ordered to give 3 units of insulin. we have special insulin syringes. they are miniscule. 3 units is barely a measurable volume. however, the night nurse chose a regular syringe. instead of drawing up three units, she drew up 0.3mL of insulin. she delivered 10 times the ordered dose. LESSON TWO: use the correct syringe.

not until midnight labs did the blood sugar get checked again. at this point, the patient's blood sugar was 51. this is critical! night nurse re-checked the patient's blood sugars at 0158. the result was 60. still critical. at this point, the night nurse woke up the nurse patient and offered her juice. when night nurse asked nurse patient if she could re-check her blood sugar later, nurse patient refused. LESSON THREE: never let patient's refuse care that is for their safety. the protocol for low blood sugars is to re-check every 15 minutes until levels return to normal.

the next re-check was done more than 4 hours later at 0636. by this time, nurse patient's blood sugar had recovered. she was back up into the 200s (which according to the orders, meant she should be getting more insulin). the night nurse told me this and said she would give the patient 2 more units before she left. my response, "i don't think so. please do not touch the patient. i do not feel comfortable with your giving her ANY insulin. i don't trust your blood sugar assessment. and i don't want to give the patient ANY insulin at the moment, until we sort this mess out." LESSON FOUR: giving feedback to nurses may result in tears, but it is essential.

i took the new nurse into the medication room, showed her the two syringes, drew up 3 units and 0.3mL and asked her to compare the difference. she laughed (not quite the response i was looking for). concerned about my patient, i ended my teaching moment and decided to proceed with my day. i rechecked my nurse patient's blood sugar; indeed, it was elevated. so i told the doctor it was high but that i was refusing to do anything about it. high is better than critically low. i did not want to give any more insulin at the time. LESSON FIVE: communication with physicians is important. documenting that communication may be even more important - to protect your license. the night nurse never once documented that she notified the on-call physician of the patient's critical lab result.

until i suggested it, the night nurse was not going to write an incident report. LESSON SIX: when you fuck up, you acknowledge it. you write an incident report, not to get yourself into trouble, but to alert someone that the system is unsafe. that somehow, you were able to make a potentially lethal error. and it could happen again unless someone assesses the system and implements safety guards.

so help nurses and our potential to hurt people.