The registered nurse and I were doing rounds when she asked me to administer insulin to a Type1 diabetic patient. The RN and I both confirmed that the amount that she requested of 24 units was what I had drawn and I proceeded to administer the same. However, on returning to take a blood sugar sample, I realized that the patient's sugar level has dropped dramatically from 14mmol/l to 3mmol/l and upon checking the medication chart, the RN and I realized that the correct amount that needed to be administered was 2.4 units of insulin.
The first thing that I felt was fear, questions started running through my head:" What have you done?" "Why didn't you read the chart carefully?" The next thing that started racing through my mind is whether any major damage had occurred in the patient's organs, whether he would soon become unconscious, and whether his heart was beating dangerously fast. All these thoughts were running through my head mixed up with emotions of regret for not being keener and at the same time feeling quite angry at myself for not taking the time to re-read the medication chart for myself and confirming the correct insulin amount before administering the same.
The incident that occurred with the patient was one of the few that I will never forget. The dominant feeling that I get every time I recall what happened is anger, and that always propels me to remember a personal mantra I created for myself: check, recheck, act, observe, re-observe. What this mantra means is that before I administer any intervention to any patient, be it an insulin shot, pain management medication, wound dressing, or even the simple act of changing the IV rehydration bag, I first check the medication/patient chart, then recheck again, I take the necessary action, then observe the patient for 1-2 minutes while asking the patient whether he/she feels comfortable or has any immediate concerns, I come back later and depending on what the action taken earlier was, I re-observe the patient accordingly.
The experience though not one I would want to see repeated, taught me one very important and positive lesson: that I should always read medication/patient charts for myself and not rely on any verbal instructions. It also drove me to think of ways that such medical errors can be avoided. During the next staff meeting, I raised the issue of medical errors that occur because of minor causes such as a colleague's handwriting. The issue was discussed in detail with other similar medical errors being highlighted and it was agreed that an electronic patient record system would be the best solution to minimizing such errors. The hospital is currently in the process of implementing an electronic medical records system.
The negative aspect of the entire experience is that the patient had to go through a potentially dangerous health situation because of an error that could easily have been avoided if only more keenness had been employed.
The error that occurred was first of all, not an isolated incident. The RN had read the medication chart and seen that it stated 24 units were needed, she then proceeded to give me verbal instructions. On reflecting over the issue, the error occurred simply because of a typographical mistake. The handwritten instructions were illegible either because whoever wrote them was in a hurry or the ink in the pen they were using to write was almost running out. Whatever the reason, the illegibility of the instructions led to a misprescription.
Prescription errors are a common and major problem in general practice (Cheragi, Manoocheri, & Mohammadnejad et al., 2013) and can increase the patient's risk of harm. Prescription errors account for significant treatment costs (Adel, Davidow, & Hollander et al., 2012) in addition to having the potential in resulting in adverse effects (Pham, Aswani, & Rosen et al., 2012).
The use of a computerized healthcare system is an ideal solution to avoiding prescription and other patient care related errors. Such a system can reduce the risk of harm to patients that may result from such errors (Nuckols, Smith, & Morton et al., 2014).
As stated earlier, I created my personal mantra which I reflect on when caring for patients. The check, recheck, act, observe, and re-observe is a way that allows me to ensure that I double check the intervention I am required to administer to the patient, take the necessary action and double check on the patient to ensure that the intervention is effective as expected. I have gone further and discussed these with my colleagues who have also taken up this way of carrying out their duties with regard to patient care.
Andel, C., Davidow, S. L., Hollander, M., & Moreno, D. A. (2012). The economics of health care quality and medical errors. Journal of health care finance, 39(1), 39.
Cheragi, M. A., Manoocheri, H., Mohammadnejad, E., & Ehsani, S. R. (2013). Types and causes of medication errors from nurse’s viewpoint. Iranian Journal of Nursing and Midwifery Research, 18(3), 228–231.
Nuckols, T. K., Smith-Spangler, C., Morton, S. C., Asch, S. M., Patel, V. M., Anderson, L. J., ... & Shekelle, P. G. (2014). The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis. Systematic reviews, 3(1), 56.
Pham, J. C., Aswani, M. S., Rosen, M., Lee, H., Huddle, M., Weeks, K., & Pronovost, P. J. (2012). Reducing medical errors and adverse events. Annual review of medicine, 63, 447-463.