# 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.

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## Question

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.

1

Implement verbal read-back and independent double-check protocols for all insulin orders

2

Report to The Joint Commission (TJC) per sentinel event policy if the facility is TJC-accredited

3

Limit the response to retraining the administering nurse rather than addressing system-level factors

4

Initiate a root cause analysis (RCA) to identify system-level contributing factors

5

Report the event to the hospital's patient safety officer as a sentinel/serious safety event

6

Complete an incident report in the institutional safety reporting system, keeping it separate from the patient's medical record

## 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).

## In-depth explanation

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.

## Clinical scenario

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.

## Key concepts

- **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

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