A charge nurse on a medical-surgical unit discovers that a patient received 10 units of regular insulin instead of 1 unit due to a decimal-point misread on a handwritten order. The patient experienced severe hypoglycemia but recovered with treatment. Which nursing actions are appropriate regarding this event? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
Correct: 1, 2, 4, 5, 6. A 10-fold insulin dosing error causing severe hypoglycemia constitutes a sentinel/serious safety event. Appropriate responses: (1) Immediate reporting to patient safety/risk management; (2) RCA using the Swiss Cheese Model — illegible handwritten order, absent independent double-check, insulin stocked adjacent to other medications all failed simultaneously; (4) Incident report filed in the safety reporting system NOT in the medical record — legal privilege protection encourages reporting without fear of litigation; (5) System-level corrective actions: verbal read-back and independent double-check for high-alert medications; (6) TJC notification per sentinel event policy within 45 days. Incorrect: (3) Disciplining only the individual nurse ignores system failures and violates the Just Culture principle, which distinguishes human error (system redesign needed) from reckless behavior (individual accountability).
Apply the Swiss Cheese Model: a 10-fold insulin error results from multiple system failures aligning simultaneously — illegible handwritten order, missing independent double-check, insulin stored alongside other medications. The Just Culture framework distinguishes human error (system fix needed) from reckless behavior (individual accountability). Key point: incident reports must be filed in a separate institutional safety system, NOT in the patient's medical record — this protects legal privilege and promotes fearless reporting. TJC classifies unexpected events causing serious harm as sentinel events and requires a comprehensive review and action plan within 45 days. FMEA is a proactive tool; RCA is reactive — both are essential quality improvement methods.
Medical-surgical unit, morning medication pass. Handwritten insulin order: "Regular insulin 1 unit SC". Nurse misreads as 10 units. Patient: 68-year-old with type 2 diabetes. BG drops to 38 mg/dL (2.1 mmol/L). Treated with D50W IV push. Patient recovers. Charge nurse is notified.
Root Cause Analysis (RCA) — A structured process that examines the systems and processes underlying an adverse event to identify contributing factors and implement system-level improvements to prevent recurrence
Just Culture — A framework that distinguishes human error (system design failure requiring process improvement) from reckless behavior (individual accountability); promotes a safety reporting culture without punitive blame
Sentinel Event — An unexpected event in a healthcare setting resulting in death, serious physical or psychological injury, or significant risk thereof; requires comprehensive review and corrective action plan per TJC standards within 45 days