MSN, RN, NPD-BC
Before becoming a nursing professional development specialist in a hospital setting, I was an adjunct clinical nursing instructor for a university. One of my hopes as a clinical instructor was that none of my students would experience a medication error under my supervision. While leading clinical groups during their rotations, my hopes came true. There were a few meltdowns, but never any medication errors. However, that all changed when I began to oversee a senior nursing practicum.
The dynamic of this position was different from my previous role. For senior practicum, I made site visits to check in with senior nursing students who were paired with a student nurse preceptor on a nursing unit. Essentially, the student nurses were permitted to complete nursing tasks with their preceptor’s signature to verify.
One evening, I received an email from a preceptor at the hospital where one of my students was completing her practicum experience. She informed me that one of my students administered the wrong dose of insulin. Her patient’s sliding scale indicated that she needed to administer 1 unit of insulin. Instead, she administered 100 units. The student noticed signs of hypoglycemia and alerted her nurse mentor.
How could this happen? Well, the student was familiar with administering subcutaneous heparin in a syringe where filling the entire syringe yielded 1ml of heparin. For this reason, in a momentary lapse of clinical judgment, she reported that she filled the entire insulin syringe to yield what she thought would be 1 unit.
There was one other factor to consider here. To administer insulin, the electronic medical record requires the signature of another nurse to document administration. That would mean that the second nurse did not properly inspect the syringe either.
Medication errors can occur in several ways, and most result from not double-checking one or several of the “rights” of medication administration. Today, we’ll focus on the importance of teaching “right dose” as it relates to syringe inspection. We can all experience medication errors, whether new or experienced. If you are a nurse educator, I encourage you to emphasize syringe inspection in “right dose” education to hopefully minimize the prevalence of medication errors.
The structures of different syringes are intentional, from the printing of the units of measurement to the increments of measurement. Choosing the correct syringe is a critical step in minimizing the incidence of dose-related medication errors.
Before opening any syringe package, check the units printed on the syringe barrel and packaging. The two common units of measurement associated with syringes are milliliters (ml) or units (U).
When adjusting the plunger, the top of the plunger (closest to the tip of the syringe) should be touching the medication at the line indicating the amount of medication you are administering. This applies if the plunger tip is flat. Be mindful that if the plunger tip is domed, although the dome is the closest to the tip of the syringe, the top ring of the plunger should be used as the gauge to measure the medication. Read the syringe at eye level to prevent parallax error.
Some modifications to the above practice should be made for some oral syringes, which may have a pointed plunger instead of flat. According to an ISMP Medication Errors report, some nurses have used the plunger tip to measure the medication, which resulted in administering more than the ordered dose. The base of the pointed tip should be used to measure the correct volume.
Remember that the larger the syringe volume, the fewer lines on the barrel. There is a combination of longer lines and smaller lines. For instance, a syringe may have larger lines that represent even numbers: 2 mL, 4 mL, 6 mL, 8 ml, and 10ml. Halfway between these lines, there may be slightly smaller lines that represent the odd numbers.
Below is a list of syringe volumes and their corresponding increment measurements for each line:
The smaller increments on a 1ml syringe allow for accurate medication of small
doses. There are some 1ml syringes that come with the needle already attached. The most common medications nurses would administer through this type of syringe are subcutaneous or intradermal medications, such as tuberculin, heparin, and insulin.
There are also other medications that would be pulled up into 1ml syringes where the nurse would attach the needle. For insulin, the dose will always be in units, although the volume that can fit in the syringe is 1ml. In reference to the aforementioned medication error, 1ml is equal to 100 units of insulin. One unit of insulin fills a tiny fraction of a 1ml syringe.
Medication errors in nursing can happen to anyone. Humans make mistakes. If we didn’t, there would be no reason for the processes designed to minimize errors. Reading syringes carefully is a vital step to preventing overdose or underdose.
Obviously, there should be double-checks with high-risk medications. However, even if there is no requirement for a second signature, always engage another nurse for a second set of eyes if you’re unsure. Nurse educators must be mindful that medication calculation is a mainstay in nursing education. Let’s take it a step further and ensure that this information extends into syringe inspection. I wish you all the best!
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