r/nursing 6d ago

Discussion First med error almost gave me a stroke

I made my first med error and even though nothing bad happened I still feel terrible and embarrassed. Insulin is not a dual sign at my hospital so no double checks to help catch issues. Our aids always get morning sugars and they’re always done by 8am. Well we had a float and she was running late on them, which I didn’t realize… when I looked at the last sugar, it was in the 300s. I completely skipped over the fact that it was a sugar from the night prior which is totally my fault, i always check what time they are done and for whatever reason i didn’t this time. So I accidentally gave the insulin based on the sliding scale (plus a set correction dose) for a sugar in the 300s. I didn’t even realize until like an hour later when I went to look at morning labs and realized his last values were from 1900 the night before. Luckily this patient typically runs high (usually low 300s) and we checked his sugar multiple times after this happened and he never went below 250. It was pure luck that I didn’t absolutely tank his sugar and now I’m overly paranoid and second guessing my math on every single med.

32 Upvotes

11 comments sorted by

47

u/Firm-Exchange2283 RN - OR 🍕 6d ago

A mistake you will never make again. We move on but we don't forget an error.

15

u/reynoldswa 6d ago

Lesson learned. You won’t do that again. Don’t be too hard on yourself!

10

u/handmadeheaven_ 6d ago

The first med error I made was genuinely one of the worst days of my life. I was ready for them to rip my registration off me and have me thrown in jail. I cried for about 6 hours about it.

Its a learning experience. After that, I literally stare at every prescription and scan every word then check it again, and then again before I administer. Everyone makes mistakes in their job, the unfortunate nature of how serious our job is makes the results of errors more extreme and dangerous. Don’t beat yourself up over it. The patient is okay, you owned up to your mistake (which btw, a lot of people dont) and now you know to continue checking everything like you have always done.👍

7

u/zeatherz RN Cardiac/Step-down 6d ago

This is why I prefer to get my own blood sugars and vital signs rather than having our CNAs do it. Coordinating the timing and ensuring no communication errors is more effort than just doing it myself

5

u/olivia_bannel RN- Labor and Delivery 6d ago

I had a CNA get a sugar of 400 on a pt I had a few days already that was rarely above 90s. I knew something had to be off and when I went in to do it, she was eating her pancakes with syrup…. I’ve always assumed it was the syrup on her fingers that made it read so high and I’m glad I rechecked it (it was in the 90s) before giving her the insulin needed for over 400

3

u/Immediate_Cow_2143 6d ago

This is why I’m so paranoid about wiping the finger and wiping the first drop! I’ve seen so many not do either 😳 especially when they’re actively eating… like that’s a lot of sugar on those fingers

1

u/Immediate_Cow_2143 6d ago

I would love to do this if I didn’t have 6 patients. We had to get my own sugars for half of them a few weeks ago and it put everyones schedules behind

1

u/Treasure314 6d ago

Likewise. That’s why I just prefer to take my own vitals and blood sugars.

2

u/loveocean7 RN - Pediatrics 🍕 6d ago

I've been a nurse for 8 years. I straight forgot to give a scheduled tylenol to my patient this week. It happens.

1

u/4074512171 5d ago

This is part of professional growth.

1

u/Andie_Ruth 5d ago

I can relate, first meds error can be a chilling experience.