The March issue of ISMP Medication Safety Alert&reg Nurse Advise-ERR&reg, reminds us all to DO NO HARM! A nurse who was unfamiliar with the Type 2 diabetic injectable medication BYETTA (exenatide) withdrew the entire contents from the penlet (1.2 mL) and injected the patient with the equivalent of 60 doses.

Once the prefilled pen is removed from the packaging, there are no instructions for use on the pen. However, it does clearly state “each prefilled pen will deliver 60 subcutaneous doses, 5 mcg per dose.” The label also states that there are 250 mcg/mL and the pen contains 1.2mL. It also states, “Do not transfer this medication to a syringe.”

Even though the instructions may have been “lost,” the nurse would find valuable information about the dosage and administration on the pen. Nurses should NEVER perform a procedure they are unsure of, nor administer a medication they are unfamiliar with until they have adequate information, instruction or supervision to ensure patient safety. (I know, there’s often not time or staffing to allow for this…. but please DON’T put your license on the line and jeopardize a patient’s safety because of staffing issues! This is not a defense, if a patient is harmed, it’s your license!)

This nurse should have asked for help before ever administering this medication. The instructions for use should not have been discarded, but this is not a defense for the nurse. She was educated and licensed as a nurse; she is expected to know better. If she had carefully read the label on the BYETTA pen, she would have gleaned the knowledge to question the dose and how o administer such a small dose.

Your first responsibility as a nurse is to protect the patient. If you’re unsure of how to do something, it is your responsibility to find out first! DO NO HARM.

The patient exhibited the signs of overdose of this medication (severe nausea and vomiting along with rapid decline in glucose levels) and was treated appropriately and recovered. But he/she should never have had to experience this.

Medicare announced late last year that they are no longer going to pay for expenses related to errors such as this one. Many private health insurance companies are following suit. Such an error could have been very costly to the facility. To say nothing of the possible loss of life to the patient.

photo by Kathy Quan

One Comment

  • Vincent Bautista

    Oh my, I wonder what happened to the patient. I hope the patient is fine. It is true that errors will happen in the clinical field, it is inevitable. But this can be but to a minimum if we always think of the patient’s sake.

    If we lack in the necessary skills and knowledge, we should be humble enough to admit this and ask for help rather than risking the safety of the patient and one’s license just to protect one’s image.

    As I have learned during my clinical exposures, never assume. There is no room for errors therefore we should always be safe. That’s why we have our 5 Rights to Drug administration (although I’ve heard there was already 10 rights).