Dangerous insulin error
While on vacation last week, I took a stack of Nursing2017 issues along to read and came across a report of an insulin dosing error (Lantus Overdose/Inexperienced RN Confused by Label, Medication Errors, February 2017). The error involved a nurse drawing up 9 mL of insulin glargine into a 10 mL syringe and injecting 900 units subcutaneously as a single 9 mL dose.
I've been an RN for 45 years and I'm glad we've gotten away from the shaming and punishment that historically followed medication errors, but it's disconcerting to read that a practicing RN could make such a serious error regarding administration of insulin-a medication nurses deal with routinely. One of the first things we learn about insulin is that it's given only with insulin syringes. An error of this caliber should result in reeducation and supervised practice until this nurse can safely administer medications to patients. We need to police ourselves to prevent such egregious errors. Nurses are repeatedly listed among the most trusted professions in the country. Let's keep it that way.
-SHERRILL DUNNING-RILEY, BSN, RN, CDE
Windsor, Calif.
Call a pro
Most nurses occasionally find themselves in situations beyond their everyday scope of practice. This problem is compounded during night shift, when fewer colleagues are available to help.1,2 Recognizing this issue, our night council sought to provide nurses with on-call assistance in real time.
More than 50% of the clinical nurses in our organization hold a national specialty certification, indicating expertise within a defined area of practice. The night-shift council surveyed RNs in each unit to identify their area of clinical expertise. The collected information was used to develop an organizational resource web page titled "Call a Pro." When staff members click on the Call a Pro icon, they're brought to a landing page containing various buttons labeled "nasogastric tubes," "intraosseous access," "chest tubes," "intravenous (I.V.) access," and more. A drop-down menu lists a unit name and phone number, providing a direct link to real-time resources.
The initial response to Call a Pro has been great; the site has proven to be useful not just for night-shift nurses, but the organization as a whole. Patients benefit by receiving high-quality care, and clinicians feel confident knowing they have the right expertise at their fingertips. This cost-effective tool can easily be adopted by other organizations.
-TONYA JOHNSON, DNP, RN, CCRN-K, NEA-BC,
RENEE GIESWEIN, BSN, RN,
HELEN LUECKE, RN, RN-BC,
JENNIFER RODDEN, BSN, RN,
JACLYN CESARE, BSN, RN,
NICOLE ZIEGLER, BSN, RN,
FRANK VISCO, BSN, RN
Philadelphia, Pa.
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