I have had a few near misses and medication mistakes as a nurse. I have learned how scanning medications and closed loop communication are very important. I had a hyperglycemic patient and the doctor ordered a bolus of Normal Saline. I took a bag out of the cabinet in the room, ripped it open, and started to prime the tubing. While doing so, I looked at the bag and it said D5W. Someone accidentally stocked the cabinets with D5W instead of Normal Saline. If I did not look at the bag or didn’t scan the medication, I would have given the hyperglycemic patient a 1L BOLUS of D5W. I think many of us know that Normal Saline is something that gets scanned the least, but when busy, something else can accidentally be hung.

I had a near miss with insulin. The doctor ordered 15 units of insulin for a hyperglycemic patient. I drew up the medication and was ready to give it intravenously. I scanned the insulin first and saw it was actually ordered subcutaneously. I froze in place and was relieved that I took the time to scan the medication before giving it. Giving 15 units intravenously and 15 units subcutaneously are completely different. Scan your meds and read the orders more than once.

I had an uncooperative psychiatric patient. The doctor verbally told me to give her 10mg of Zyprexa. I went to the pyxis, grabbed a 10mg vial of Zyprexa, mixed it, and drew it up to give it intramuscularly. A few coworkers came in the room with me just in case the patient got aggressive. I gave her the IM shot. Afterwards, I looked at the computer and the doctor put in an order for 10mg oral Zyprexa. I was mortified. I told my coworker who was a nurse for 15 years and luckily she told the doctor that we didn’t have oral Zyprexa down here and if we could just give it intramuscularly. The doctor said ok and I was beyond relieved. I thanked and thanked my coworker. Now I make sure I always use closed loop communication. Luckily, the Zyprexa just calmed the patient down and didn’t completely knock her out like it does to some people.