| Contents | Previous | Next |
Mr. Ferguson and Mr. Redpath, two diabetic patients assigned to the same room, had orders for glucose tests to be followed by insulin administration as needed.
The nurse caring for these two patients was very busy, so she asked the nursing assistant to perform the tests. The assistant did so and gave the nurse values indicating that Mr. Ferguson didn't need insulin whereas Mr. Redpath did. The nurse administered insulin to Mr. Redpath, as ordered, then went to dinner.
Within a few minutes, the nurse was paged and asked to return to the unit immediately. When she got there, Mr. Redpath was being treated for hypoglycemia. The nurse quickly checked Mr. Redpath's glucose test sheet and saw that the assistant had charted his test result as 90 mg/100 ml-an amount not requiring insulin. She then checked Mr. Ferguson's test sheet and saw that his result had been charted with the value she'd been given for Mr. Redpath. At this point, the nurse realized that the assistant had misinformed her, and she'd given the insulin to the wrong patient.
After Mr. Redpath's condition had stabilized and Mr. Ferguson had been given the appropriate dose of insulin, the head nurse called the nurse and the assistant into her office. She told them they shared the responsibility for this error. Referring to the hospital's policy and procedure manual, the head nurse pointed out that the nurse who administered insulin is responsible for performing the tests that determine the need for insulin.
Although this is a good policy to follow, it may not be practical for all hospitals. The best way to avoid such an error is to be sure all information you convey is accurate