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A new nurse makes a mistake

The five "rights" of
medication safety

right medication

right patient

right dose

right route

right time

It was her first day off orientation as a nurse at Melrose-Wakefield Hospital and an extremely busy day on her inpatient floor. Among her patients was a very sick man with a tracheostomy and a feeding tube. He also had diabetes and required regular administrations of insulin.

“I was running behind and had several patients who needed their meds,” she said. Many patients with diabetes are on a sliding scale of medications; the dose varies depending on the blood sugar level. The policy for sliding-scale insulin administration is to get a co-signer for the medication “to doublecheck that the dose is correct,” she added. She found a fellow nurse – someone with 20 years of experience – who co-signed and the patient got his insulin. Because it was so busy, the dose was not verified and the patient received a higher dose than he needed.

“I didn’t realize I’d made an error until I got to my next patient and was following the protocol,” she said. She immediately told the charge nurse, who called a supervisor and a physician. The patient was given a second medication to counteract the extra insulin and was monitored closely overnight. Fortunately, the error did not cause him harm.

“I felt terrible. I don’t know how I made it through that first shift,” she said. “I was going to quit. But everyone was very supportive. I sat down with senior managers and we talked about how the error happened and what processes could be put in place to minimize the chance of this type of error happening again.”

She has learned three very valuable lessons. “First, stop and think. Ask yourself ‘does this make sense for this patient’? Second, take your time when administering medications, even if you are being pulled in several directions, and follow the policies in place. And third, speak up when you make an error. It’s much better to be embarrassed than to have harmed a patient!”

 

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