When I was a new nurse, I made my first medication error with one of the deadliest of medications that we handle. Insulin. Looking back, this is a painful story, but it bears telling as there are clear lessons to be taken from it. I was still working dayshift, and it was toward the end of my shift when I called a physician for an order. I don’t remember the circumstances, but I clearly remember the order being given to me. I was nervous, as this doctor was not kind nor patient to nurses. He told me to give a certain number of units. He did not tell me what type of insulin to use. I did not ask. I gave the patient Regular insulin in a dose intended to be NPH, a dose higher than the number 20.

I compounded this error by not recognizing what I had done until I sat bolt upright in bed around 3am that night. I remember being dramatic and angry with a doctor who left the patient right before my shift ended, accusing him of causing her to be in distress by not replacing her oxygen mask. Oh, my arrogance was palpable and flawed. She was in distress because I had caused her to have insulin shock.

When I frantically dialed into work that night, my heart racing and my palms sweaty, it was my mentor who answered the phone. When I told her with fear in my voice what I had done, her reply was loaded with disappointment and severity. They had figured it out and saved her life. She ended up needing two more days in a higher level of care, but she lived. I went to the patient that next day and told her what I had done. I apologized. She forgave me, but she looked at me with glinting, angry eyes. Eyes that knew I had not done my best, that I had not even come close.

Here are the mistakes that I made and they are huge. Please learn from them.

1. I was afraid of the physician. I was afraid to sound like I didn’t already know what he was saying. I was afraid he would think I was ignorant (which I was!). It is better to sound like a complete idiot and take a tongue lashing than to harm a patient.

2. I did not read back the telephone order. I did not clarify. I did not get all of the ordering information. I did not call the physician back to get the full information. It only takes a minute to save a lifetime of regret.

3. I did not think about insulin when I drew it up. I did not recognize its power. I did not think about why I was giving it and how it would affect the patient now and later. I did not stop and think. There is a reason we are taught the details about the medications we give.

4. I did not ask another nurse. This was before it was required to get a second signature for insulin administration. You are never alone.

5. I did not think about what I was doing when I administered the insulin. I did not stop for a moment and think to myself, WHY am I giving this? WHAT will it do to the patient? HOW fast will it work? HOW long will it work? WHEN will it peak? HOW is it metabolized? HOW is it excreted? Does this seem like a proper amount? There is a huge difference between the five rights and actual thought. The five rights only work if you use your critical thinking to assess them.

6. I did not look at the patient and think. I saw she was pale, sweaty, and glassy-eyed. I saw her clearly and blamed something and someone else. When I replaced her oxygen, I did not stay and watch her for a moment to see if she improved. This, in my opinion, was my gravest error. She saw me come in while she was in distress, place her oxygen back on her face, and then turn away from her to go give report. She was too far gone to tell me what was wrong with her words, but it was obvious in her appearance. YOU are the only voice for your patients. Pay attention and focus.