Tuesday, June 3, 2008



1. Right Patient
2. Right Time
3. Right Medication
4. Right Dose
5. Right Route


1. Falling asleep before taking bedtime Insulin dose
2. Waking up and panicking
3. Deciding to take insulin while not fully awake.
4. Not reading label of Insulin vial before drawing up medication
5.Injecting self with 80 units of Humalog thinking it was 80 Lantus! (Oh Sh*t!)

(Humalog is short acting insulin peaks in 2 hrs, lasts 4 hrs- Lantus long acting, lasts 24hrs!!)

This little ole man(LOM) was so embarrassed about what he did and of not being able to keep his sugars up at home when he realized what he had done. As a 20+ year insulin dependent diabetic he knew better. He stayed with me for hours on a sugar drip (D5,45%NS) and me bolusing him with even more sugar (D50) every hour. I also stuffed him full of every protein ladden food I could get my hands on.

LOM apologized every time I came into his room for bothering us and messing up so bad. I gave a little nursing education about the "5 Rights" we as nurses live by. And he promised never to make this mistake again...

But if it did, I want him embarrassed in the ER with me rather than at home trying to save face..

Because this is a LETHAL mistake, I can easily fix with just a little chiding added on.

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