NursingZen

One month ago
I gave a patient Aspirin and Plavix, not realizing that he already received the once-daily dose at a different hospital before he transferred to the one I work at. A nurse told me about the error the next day and apologized for having to report it on a “Responsible Reporting Form.” I was shaken by the news – both of the meds reduce the blood’s ability to coagulate. Luckily, the doses were relatively small and the patient was unharmed. Still, I was kicking myself and terribly annoyed by the “med reconciliation” process, which I think is highly susceptible to errors.

One week ago
I gave a scheduled dose of 10 units NPH insulin along with a sliding scale dose of 10 units of Aspart – except that I didn’t actually give NPH; I gave Novolin 70/30, which I mistook for “NPH” and later learned is 70% Aspart and 30% NPH. This means I gave a patient too much rapid-acting insulin, which would bring his blood sugar down, fast.

Just as I was going home, the nurse who had “double checked” my insulin noticed that Novolin 70/30 was in the med room labeled with the patient’s name. She asked if I had given 70/30 or NPH.

The chain of errors immediately flashed before my eyes:
- I went to the Pyxis to get NPH.
- NPH was grayed out/not available in the Pyxis.
- I caught sight of a bottle of insulin on the counter with the patient’s name on it.
- I looked at the label and saw “NPH.” It didn’t register in my mind that there was also the word “Aspart” or that it said “Novolin 70/30.”
- I drew up the insulin in the med room and outside of the med room, asked a nurse to check my doses and co-sign.
- She didn’t see from what vials I had drawn the insulin.

And so there we were. Mild panic and disbelief as to why I gave 70/30. Didn’t I know the difference? The shameful truth is, I didn’t.

I notified the doctor, who was very nice. He ordered every-hour blood sugar checks for a few hours.

The nurse, while astounded by my ignorance, also kicked herself for not doing a real double check.

We also blamed Pharmacy for sending up Novolin 70/30 with the patient’s name on it.

I didn’t sleep well.

The next day I studied my insulins like I should have before. But I was also cursing and shaking my head – why is the naming of the different insulins so alike?

Thankfully, the patient was unharmed.

For a few days I was despondent and angry with myself and with the hospital system we work in. The errors were my fault, no doubt about it. But it’s also true that the hospital system, the “flow” as one veteran called it, sets the stage for us to make mistakes and take short cuts.

I’m still shaken up by last weekend’s mistake, but I’m also extremely motivated and determined to not make another med error again. I might even be a little paranoid now, but paranoia is probably a good thing in acute care.