Dodged a bullet

Image: Blend Images Photography | Veer
As a nurse we have hundreds, if not thousands of things to do and remember each and every day.  We have become masters of multitasking, or so we think.  Is it any wonder that we make mistakes?  The biggest part is trying to minimize the damage of those mistakes, take responsibility for our mistakes and learn from those mistakes so we don’t make them again.
I have my fair share of mistakes too, here is one of my most memorable, that thankfully did not hurt anyone, but taught me a lesson I will never forget.

When I was a new RN in an extremely busy emergency room, right off orientation, I had a patient come in for diabetic ketoacidosis (DKA).  This is the first time I had actually cared for a patient in DKA, and I really didn’t know what I was doing, but it was a busy day in the ED so I didn’t ask for help. 

I got an order for regular insulin 10 units IV push.  But, it was hand written, and I read the order as regular insulin 100 IV push, because the u was written so that the top parts of the U intersected and looked like another zero.  I went and drew up the insulin, which took two syringes, which should have been my first warning, actually about my fifth or sixth warning.  I remember thinking, this is not right, but I have never taken care of a DKA patient before, so it must be right.

I gave the insulin and instantly thought, I should ask.  After I did it, I went to the physician who wrote the order and she stated it was 10 units.  I thought I was going to pass out, I thought I killed the guy.

His blood sugar was around 800 when he came in.  I immediately told the physician and the charge nurse.  I started taking blood sugars every 5 minutes for the next couple of hours while he was in the ED before we transferred him to the ED.

His blood sugar never dropped more than 10 points the entire two hours.  After he was transferred to the ICU, I kept looking up his labs, and it still didn’t drop after about 8 hours.  The next morning when I got to work, I went up to the ICU and his blood sugar was still in the 600’s.

I dodged a huge bullet.  I could have, or probably should have, killed this guy.  I was reckless for not asking the physician.  I was irresponsible for not asking for help.  I was foolish for trying to take care of a patient was not qualified, or prepared to care for.

I did learn from this incident.  I learned to ask for help.  I learned to ask for clarification.  And most importantly, I learned to stop and critically think before I act.

This is one of my major ones, but I have a ton of them if you ever want to hear them.

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