Reference no: EM133310044

Case Study: I had just started my shift on the cardiac care unit. The unit was extremely busy, and we were short an RN & an LPN. It was my first shift after a set of days off. I didn't know any of the patients, and the unit was chaotic with a bunch of new admissions. One of the cardiologists had just done rounds and most of my patients had new orders. Mr. Dyer was one of my patients and he was due for his insulin. I had checked his glucometer and his glucose was high. I went to look at his sliding scale, but there were new orders. For his current blood glucose of 9.2, I read the new order the doctor had just handwritten. It said, for blood glucose 8.9-10.0, give Humulog 20 sc. I got the insulin, checked the vial to be sure it was the right insulin, and drew up 20 units of insulin. I had another nurse check what I had drawn up, then I went to Mr. Dyer's room. I checked his wristband, and explained I was going to give him his insulin. He said ok and I prepared his skin and administered the insulin. I gave him his call bell and told him I would be busy with other patients for the next while, and to use the call bell if he needed anything. I documented the injection and went to see my next patient. About half an hour later, I was busy with other patients when Mr. Dyer's call bell went off. When I went in his room, his face was pale and diaphoretic. His hand on the call bell was shaking and he had trouble talking to me. He was clearly confused and drowsy. I immediately thought he was having an insulin reaction, so I grabbed a glucometer and tested his blood glucose: it was only 1.8! I called for some help and we treated him with D50W. Fortunately, he was ok. When we reviewed the incident, it turns out that the order had been written Humulog 2 u, not 20. I mistook the abbreviation "u for units" as a 0. I realize now I should have questioned the amount of insulin. But I didn't know the patient, I didn't know his usual amount of insulin, and I was in a rush. That was one of the worst moments in my career, realizing I had overdosed him on insulin.

Question 1. What are two things this nurse could have done differently?

Question 2. Is the nurse who verified the insulin for the nurse at fault as well?

Question 3. What would you do if this happened to you?

Question 4. What can you do as a future practical nurse to avoid these types of situations from happening?