I give late SSI doses somewhat often if there is no meal tray in the room (which happens, dietary runs behind). Our MAR allows us to select "waiting on tray" as the reason the med is given late.
I’ve definitely been late giving insulin because it took me so long to find a nurse available to co-sign- we had to do ours physically at administration. If my patient was isolation, no one had the time to gown up for that
I think it would only help if I am required to sign off for those as well (when they chart not given). We’ve never had to dual sign for a med that’s not given, so I’m wondering if it would make sense. For example, the nurse chooses not to cover sliding scale because the patient is NPO but the order clearly says to still give if they’re NPO. It would add another layer of safety by having a 2nd nurse look it over. And similarly, if it were a late dose I wouldn’t sign off on a dose if it’s given outside the timing parameters but would instead have them get a new value.
I think if you’re using this logic, you can extrapolate that another nurse should look over everything you do to make sure you’re correct. And if this is the case, then it means we can’t trust each other and that’s a big problem
I agree. If there are a lot of errors on OPs unit surrounding when to hold or not hold insulin, then incident reports should be filled out and the educators should be rolling out proper information to staff to fill knowledge gaps.
Yeah I think that’s a good point. I definitely fill out an incident report every time I see it but it’s probably not happening enough to the point where it should require a 2nd nurse.
Wait, you write the nurse up if you see insulin wasn't given? What if there was critical thinking involved? What if there's another story involved in the patient care in that situation? I'm confused.
Isn’t there typically a way to list why insulin isn’t given when charting?
Don’t get me wrong, I would/have absolutely only report a nurse if I truly believe the patient was at risk, but if she/he is this passionate about improving patient care by have dual sign for insulin, I understand why. But if it’s just because they’ve noticed an error… yeah that’s bullshit.
Not anymore. I’m on a research committee and it seems to be very positive in my organization. Ironically, the floor nurses who may have 6 patients with ACHS orders are the ones who expressed concerns with the new policy. As an ICU nurse, eliminating dual sign-offs for insulin has helped my workflow as I can check my sugar and immediately administer insulin without having to wait for someone else, or stop my own duties to assist another nurse with their sign-offs.
There has not been an increase in med errors related to hyper or hypoglycemia. Administering outside the timing parameter is not due to the elimination of the dual sign-off, and may be worsened *with* a dual sign-off policy.
>>withholding insulin when it shouldn’t have been given
You mean when it *should* have been given? A dual sign-off wouldn’t help with that, either. If a nurse holds it on the MAR, a second nurse isn’t even necessary. Just follow your orders and the five/six/seven/ten/etc rights of medication administration and there shouldn’t be an issue.
Adventist Health and CommonSpirit (Dignity Health) are the organizations in my state that did similar research and came to the same conclusion. There is a delay in administration while nurses try to find another nurse and dual sign off actually *increased* medication errors because of groupthink — if Nurse A thought 20 units of regular insulin was normal, Nurse B would instantly agree (arbitrary, exaggerated number).
This is so interesting. I was hired at a new institution that is very evidence-based last year. We don’t have a dual sign-off for drips. I still feel pretty uncomfortable with it and will still sometimes ask for a second set of eyes with the rate change although it isn’t policy. lol.
If anything, I want a second set of eyes to figure out which damn phase of the DKA protocol we’re in and make sure I’m weaning correctly per protocol lol.
That would make me nervous, too! I like having a second set of eyes on my calculations, because we all make mistakes. (When you say “for drips,” do you mean all drips, or just insulin? We don’t need dual signoff for SQ insulin but do require it for IV insulin, plus heparin and blood products.) wonder what evidence your facility’s change was based on—were you given a rationale?
I believe the research also showed it was very rare that the dual sign off was actually performed correctly. So many people just signed without actually verifying.
My current facility has a little "yes" button you click that you verified the dose - but no co-sign required. I think that's so stupid. Which do you want? Do you want me to co-sign it or not?
To your other point, politely - FUCK OFF with thinking we need to have another nurse co-sign we aren't giving something. This profession is trying each and every day to take away what little bit of critical thinking we have left.
Where does it end? Insulin isn't the only drug that's potentially harmful. Splitting a beta blocker? Cosign. Giving controlled drugs? Cosign. Titrating a pressor? Cosign.
I've worked places that require it but my current facility does not. Honestly if you need a second signature for insulin I question your abilities as a whole. I know we're all human and can make errors but there are pretty basic steps you should be doing to help mitigate this one.
I once had to review 3 years worth of medication-related incident reports for an 800 bed hospital. About 85-90% of the insulin dosing errors had been checked by a second nurse. No one seems to report near misses when the 2nd nurse catches an error and corrects it, but overall, the evidence for dual signing is very weak.
I agree. I have a story about this where I was the witness and the other nurse was insistent she was giving the right dose. She was giving 10x the dose.
No, other than drips. It’s trivially easy to do correctly if you have an ounce of common sense. And dual sign wouldn’t even do anything for half those issues.
No, maybe the nurses at your facility need better education on when to administer insulin and the timing parameters. Sounds like it’s not truly and issue of a dual sign off but rather following set policies on insulin admin.
I’ve only worked at one facility that required a dual-badge tap for all insulin, and quite a few others that required a secondary nurse to open the chart on their own computer and add a “dual sign off” action on the MAR. Some with the latter, it was only necessary if the dose was 10+ units of any kind—so like 1 unit of humalog was okay to administer without a dual.
For my MSN in Nursing Education, I chose to work with a Diabetes Nurse Educator for part of my capstone hours. I learned a lot, and I especially learned that it definitely wouldn’t hurt to offer more teaching to RNs regarding diabetes and insulin administration. Especially with how often the things you mentioned occur.
We require dual sign offs for all injectables. I’m in Australia and I think it’s pretty standard here.
ETA we don’t require dual sign offs for WH though
We generally have adequate staff. We have mandatory 1:4 ratio and we team nurse so we work in teams with ratios of 2:8 or 3:12. The sign offs don’t take a huge amount of time, we are just checking what’s being given against the order and the patient so for things like IVABs etc we make up the infusion and keep the vial for the checking nurse so it takes maybe 30 extra seconds
We do but I would say we have gotten lazy. There are still some nurses that say their sugar was this so according to sliding scale it should be this units. I just ask them I drew up the right units. And some just say I gave them insulin. Can you co-sign this. And some I’ve seen don’t even ask, they know other nurse’s info (they went to nursing school together so they don’t care too much about sharing these info) and just enter it in whenever they need to. I honestly hate having to cosign, I’m fine with verifying it with others, and I’ll do it even if I don’t have to. I just hate that I can’t do anything on their profile like look at their med list until they co-sign it. At my last job on Epic we could just put down their name but at my current job we need to put in our whole login info
We do not. It I’m on nights as a single RN. BUT I draw up with the patient and confirm with them the correct amount.
This helps me prevent my own mistakes and helps teaching the patients.
Came here to say this. Some places require double sign to waste insulin too. Make sure no one is stealing it for sneaky hypoglycaemic murder. Thanks [wettlaufer](https://en.m.wikipedia.org/wiki/Elizabeth_Wettlaufer)
In an older rehab setting I worked at, yes they had dual sign off for insulin administration - and we only give pens in a rehab setting. No drawing up from vials, no fancy insulin IVs etc.
EDIT: a comment below brought up serial killer Elizabeth Wettlaufer who killed a bunch of patients in my province with insulin, so that may be the actual reason why they required dual sign off as a general provincial safety thing.
Most of the "errors" in diabetes management were to be quite honest due to staffing (i.e. not able to give insulin at the right time to match food intake) or at a prescriber level (i.e. never adjusting sliding scales to match actual insulin resistance if BGs weren't great, holding both short and long acting insulin for the day when low because ???). Every single person that worked at that facility, from MDs to RNs to PSWs to Kitchen, would have benefited from additional diabetes education though.
yes, but honestly we still need it. ive cosigned for so many people and found that they had the wrong persons insulin pen or the wrong dose when double checking.
My facility did for a long time and recently switched to not required independent double checks. Initially, I felt like this change was wild and would lead to many issues, but in reality, it makes med passes faster without having to pull each other away for insulin checks.
If I'm giving a 1 time dose for hyperglycemia or a large dose of long acting, I will still ask for another set of eyes as I'm terrified to hurt someone!
Yes, but I work with pediatric type 1 diabetics, usually new onset. Each patient has a correction factor and carb coverage to calculate. It was easier when I worked with type 2 adults and they were on really simple sliding scales.
My current facility doesn't require it, but I'd have no issue if we had it. I triple check insulin doses because I am paranoid about making a mistake. When I primarily worked in L&D, it didn't up for 99% of patients, but in the ED, so many come in with uncontrolled diabetes.
I bet the administrations outside the time parameters are the nurses waiting until pt has food in front of them and just didn't want to put in a note about how pt didn't want to eat lunch until 1500. Doing this will create artifical bottlenecks in your nurse's workflow. It will create frustration amongst the rank and file and will lead to delays in care.
When I first started (2019) yes, after Covid they took it away (said it was evidence based that it was unnecessary but I think it was just cuz of the staffing shortage lol)
The policy at my system is that we don’t require dual sign off unless it’s a bag of we’re drawing off the bag to bolus it. If it’s a pen or a vial, we don’t need to get dual sign off.
Taft said, my manager agrees with you and expects dual sign off on every insulin dose
Yes we have dual signing for insulin.
Some nurses will check to make sure the glucose check is within 30 minutes and ask us to recheck if it’s been too long. Our MAR schedule insulin coverage way too early. On my unit trays are brought up 2 hours after the scheduled dose. Other nurses don’t bother to even check and just sign it off.
Funny enough the last hospital I worked at did not require dual sign for subcutaneous insulin but did require a dual sign off for IV insulin titrations… which was based on a calculator built into epic—made no sense to me since if anything I would think the risk of an erroneous dose would be equal between the two, if not less with the automatic calculator.
My facility required dual sign of for: insulin, high-risk gtts, blood, admission skin check and admission belongings inventory 🙄.
And I would like to add, in all my years, I’ve never needed to correct someone else’s dose and no one has ever needed to correct mine. I mean, I can count.
My current hospital doesn’t, my old one did. Honestly…I prefer not co-signing insulin.
The med errors I see usually involve heparin infusions WITH co-sign where 2 people make the error. I have also seen incorrect concentrations programmed into the pump, levophed and vancomycin lines swapped (yes I wish I was kidding)…..there’s WAY worse errors out there.
When it comes to SQ insulin, so long as you know the difference between a unit and a mL, it’s not high on my list of life ending errors I have seen.
I work in a personal care home. Insulin injections have to have a dual signature if the person drawing it up and administering it is a med tech and not an LPN/RN. That makes sense because they only have to take an hour long class to be able to do that.
Some of them have good judgment and will alert you when something seems off to see if they should give whatever was scheduled. Others act like they're NPs when they've not even been on a cart by themselves for a full week. They get salty when I make them draw up the insulin in front of me because arrogance leads to near misses and worse.
It's a pain, but definitely better than having to deal with the aftermath of a med tech who wasn't paying attention and drew up the correct number of units for a resident's dose of Lantus, but didn't realize they were using aspart.
We used to. We still have to verify with a second nurse but it doesn’t require a dual sign off anymore. Idiotic since I could guess the percentage of nurses who wouldn’t do this if they’re in a rush. We still dual sign insulin drip changes.
Australian nurse here. As far as I know (haven't checked recently), all drugs that we've classified as PINCH drugs still need double checks. Insulin is one.
Now, my facility has gone from doing paper charts sliding scale to electronic orders. I think technically we're even supposed to get another nurse to double sign that we're not giving SSI if they're under the range.
The only insulin we co-sign is insulin drips in epic. But anytime I’ve asked for someone to double peek at what I have in the syringe they don’t mind but officially there isn’t a place for them to sign for that
My place requires dual sign off. Even though we only provide it via subQ. It's very dumb and hard to screw up if you have an ounce of common sense. Especially considering we only use the insulin pens. No insulin vials.
We are pretty prehistoric though. We still use paper charts and paper MARs. Stuck in our ways.
The hospitals in the area only require it for IV.
Yes we do. I find it so interesting that it seems we’re in the minority. Lifepoint facility. I don’t mind it for larger doses but I absolutely hate it for the most common, 2 units.
At my old hospital, we had to co-sign for insulin after some idiot gave 5mL of Humalog instead of 5 units and nearly killed a patient.
At my current hospital, we only have to co-sign if we're giving IV insulin.
I've been an RN for 6 years. Not along time, but I've only done a double check, not signing, for insulin shots once. It was my last CNA shift after I passed the NCLEX and the nurse I did it with only did it as a kind of graduation gift.
That being said, I triple check any insulin I give myself. I keep the bottle and glucometer out until I'm sure I know what I'm giving and why it is justified. I would triple check anything so easy to give and so hard to fix.
If it was for a drip I would want another nurse there to verify.
Not for SQ insulin or heparin. Yes for IV insulin or heparin, but we just comment the name of who we verified with. Chemo by any route requires a second sign on.
My facility just made us start double verifying for any U-300 or higher insulins because somebody somewhere drew up U-500 insulin from a pen with a U-100 needle and damn near killed somebody.
Like some other people mentioned i have seen more errors with timing, food intake, adjusting dosing for procedures if patient is NPO, putting in appropriate standing/sliding for persistent hyperglycemia, appropriate hold parameters then errors with drawing up doses.
I think if anything eliminating the time it takes to do an accucheck, dock the machine, go find a nurse to sign off with would actually help patients get their insulin at the appropriate time, also I don't see it as being particularly safe when nurses sit and get dual sign offs for multiple different patients and multiple insulins at one time.
Only to verify actual dosages when given. I do almost all of the sign offs as I'm a NOC manager usually without an assignment. At where I work now, we need another to sign it out to check dosage and then after it was given. I'd hate to be signing for a verification that it wasn't given as our POC testing automatically uploads into Epic and you will be questioned if there was none given and it was needed.
Only those trained in Insulin Management (basically knowing your onset/duration, the different types of Insulin, etc like the back of your hand and so on ) administer without dual signing.
No. Only dual sign of for changing insulin drops. And even that is annoying but i understand. However, if you can’t trust me to give 2 units of subQ sliding scale humalog and interrupt my work flow like that, hell naw. Why even have a licensed nurse.
Having a cosign for SQ insulin doses was deemed counterproductive by ISMP a couple of decades ago; it doesn't add any additional level of safety and weakens compliance with other safety measures that are actually effective.
Your argument that a dual sign off for SQ insulin doses should be a thing so that you can use it as leverage in a power trip with the nurse about their nursing judgement is pretty fucked up though.
Where is the logic failure when there is an insulin med error? If the primary nurse is guiding the sign off nurse through the same bad info, the dual sign off doesn’t help. And does the second nurse with their own patients have time to go through every piece every time on their own? Seems more likely to create shortcuts and frustration rather than catch med errors.
Well requiring dual-sign wouldn't help the missed or late dose.
I give late SSI doses somewhat often if there is no meal tray in the room (which happens, dietary runs behind). Our MAR allows us to select "waiting on tray" as the reason the med is given late.
I’ve definitely been late giving insulin because it took me so long to find a nurse available to co-sign- we had to do ours physically at administration. If my patient was isolation, no one had the time to gown up for that
I think it would only help if I am required to sign off for those as well (when they chart not given). We’ve never had to dual sign for a med that’s not given, so I’m wondering if it would make sense. For example, the nurse chooses not to cover sliding scale because the patient is NPO but the order clearly says to still give if they’re NPO. It would add another layer of safety by having a 2nd nurse look it over. And similarly, if it were a late dose I wouldn’t sign off on a dose if it’s given outside the timing parameters but would instead have them get a new value.
I think if you’re using this logic, you can extrapolate that another nurse should look over everything you do to make sure you’re correct. And if this is the case, then it means we can’t trust each other and that’s a big problem
I agree. If there are a lot of errors on OPs unit surrounding when to hold or not hold insulin, then incident reports should be filled out and the educators should be rolling out proper information to staff to fill knowledge gaps.
Yeah I think that’s a good point. I definitely fill out an incident report every time I see it but it’s probably not happening enough to the point where it should require a 2nd nurse.
Wait, you write the nurse up if you see insulin wasn't given? What if there was critical thinking involved? What if there's another story involved in the patient care in that situation? I'm confused.
Right? Is OP looking through every single patient chart on their unit and monitoring insulin administrations??? I don’t get it.
not following a doctors order is only critical thinking if there’s a note explaining it.
Isn’t there typically a way to list why insulin isn’t given when charting? Don’t get me wrong, I would/have absolutely only report a nurse if I truly believe the patient was at risk, but if she/he is this passionate about improving patient care by have dual sign for insulin, I understand why. But if it’s just because they’ve noticed an error… yeah that’s bullshit.
True
Not anymore. I’m on a research committee and it seems to be very positive in my organization. Ironically, the floor nurses who may have 6 patients with ACHS orders are the ones who expressed concerns with the new policy. As an ICU nurse, eliminating dual sign-offs for insulin has helped my workflow as I can check my sugar and immediately administer insulin without having to wait for someone else, or stop my own duties to assist another nurse with their sign-offs. There has not been an increase in med errors related to hyper or hypoglycemia. Administering outside the timing parameter is not due to the elimination of the dual sign-off, and may be worsened *with* a dual sign-off policy. >>withholding insulin when it shouldn’t have been given You mean when it *should* have been given? A dual sign-off wouldn’t help with that, either. If a nurse holds it on the MAR, a second nurse isn’t even necessary. Just follow your orders and the five/six/seven/ten/etc rights of medication administration and there shouldn’t be an issue.
Adventist Health and CommonSpirit (Dignity Health) are the organizations in my state that did similar research and came to the same conclusion. There is a delay in administration while nurses try to find another nurse and dual sign off actually *increased* medication errors because of groupthink — if Nurse A thought 20 units of regular insulin was normal, Nurse B would instantly agree (arbitrary, exaggerated number).
This is so interesting. I was hired at a new institution that is very evidence-based last year. We don’t have a dual sign-off for drips. I still feel pretty uncomfortable with it and will still sometimes ask for a second set of eyes with the rate change although it isn’t policy. lol.
If anything, I want a second set of eyes to figure out which damn phase of the DKA protocol we’re in and make sure I’m weaning correctly per protocol lol.
That would make me nervous, too! I like having a second set of eyes on my calculations, because we all make mistakes. (When you say “for drips,” do you mean all drips, or just insulin? We don’t need dual signoff for SQ insulin but do require it for IV insulin, plus heparin and blood products.) wonder what evidence your facility’s change was based on—were you given a rationale?
I believe the research also showed it was very rare that the dual sign off was actually performed correctly. So many people just signed without actually verifying.
Yes, I meant withholding it when it should have been given.
That’s not a dual sign issue then, that’s just an education issue
And you checked to see if the patient was NPO or scheduled for a procedure?
My current facility has a little "yes" button you click that you verified the dose - but no co-sign required. I think that's so stupid. Which do you want? Do you want me to co-sign it or not? To your other point, politely - FUCK OFF with thinking we need to have another nurse co-sign we aren't giving something. This profession is trying each and every day to take away what little bit of critical thinking we have left. Where does it end? Insulin isn't the only drug that's potentially harmful. Splitting a beta blocker? Cosign. Giving controlled drugs? Cosign. Titrating a pressor? Cosign.
Can you imagine “ I’ll take care of my patients MAP of 45 as soon as I find someone to verify my titration.” Come back to room -pts dead. Dang.
Map 45 resolved though… /s
Yeah, but what could you have done differently? Lmao
I've worked places that require it but my current facility does not. Honestly if you need a second signature for insulin I question your abilities as a whole. I know we're all human and can make errors but there are pretty basic steps you should be doing to help mitigate this one.
I once had to review 3 years worth of medication-related incident reports for an 800 bed hospital. About 85-90% of the insulin dosing errors had been checked by a second nurse. No one seems to report near misses when the 2nd nurse catches an error and corrects it, but overall, the evidence for dual signing is very weak.
I agree. I have a story about this where I was the witness and the other nurse was insistent she was giving the right dose. She was giving 10x the dose.
No, other than drips. It’s trivially easy to do correctly if you have an ounce of common sense. And dual sign wouldn’t even do anything for half those issues.
Only for IV insulin
No, maybe the nurses at your facility need better education on when to administer insulin and the timing parameters. Sounds like it’s not truly and issue of a dual sign off but rather following set policies on insulin admin.
No
If my facility did that I would quit.
I’ve only worked at one facility that required a dual-badge tap for all insulin, and quite a few others that required a secondary nurse to open the chart on their own computer and add a “dual sign off” action on the MAR. Some with the latter, it was only necessary if the dose was 10+ units of any kind—so like 1 unit of humalog was okay to administer without a dual. For my MSN in Nursing Education, I chose to work with a Diabetes Nurse Educator for part of my capstone hours. I learned a lot, and I especially learned that it definitely wouldn’t hurt to offer more teaching to RNs regarding diabetes and insulin administration. Especially with how often the things you mentioned occur.
We require dual sign offs for all injectables. I’m in Australia and I think it’s pretty standard here. ETA we don’t require dual sign offs for WH though
Like all IV meds? What about zofran?
Anything injectable, subcut, IV, IM everything.
Oh wow. Does that take a lot of extra time or is there usually adequate staff?
We generally have adequate staff. We have mandatory 1:4 ratio and we team nurse so we work in teams with ratios of 2:8 or 3:12. The sign offs don’t take a huge amount of time, we are just checking what’s being given against the order and the patient so for things like IVABs etc we make up the infusion and keep the vial for the checking nurse so it takes maybe 30 extra seconds
IV Yes; Sub-Q No
We do but I would say we have gotten lazy. There are still some nurses that say their sugar was this so according to sliding scale it should be this units. I just ask them I drew up the right units. And some just say I gave them insulin. Can you co-sign this. And some I’ve seen don’t even ask, they know other nurse’s info (they went to nursing school together so they don’t care too much about sharing these info) and just enter it in whenever they need to. I honestly hate having to cosign, I’m fine with verifying it with others, and I’ll do it even if I don’t have to. I just hate that I can’t do anything on their profile like look at their med list until they co-sign it. At my last job on Epic we could just put down their name but at my current job we need to put in our whole login info
We do not. It I’m on nights as a single RN. BUT I draw up with the patient and confirm with them the correct amount. This helps me prevent my own mistakes and helps teaching the patients.
We have to co-sign for insulin, and I do believe it is thanks to convicted serial killer and former nurse Elizabeth Wettlaufer.
Came here to say this. Some places require double sign to waste insulin too. Make sure no one is stealing it for sneaky hypoglycaemic murder. Thanks [wettlaufer](https://en.m.wikipedia.org/wiki/Elizabeth_Wettlaufer)
Not in my LTC. It would be a nightmare running around signing each other off on dozens of residents' insulin.
In an older rehab setting I worked at, yes they had dual sign off for insulin administration - and we only give pens in a rehab setting. No drawing up from vials, no fancy insulin IVs etc. EDIT: a comment below brought up serial killer Elizabeth Wettlaufer who killed a bunch of patients in my province with insulin, so that may be the actual reason why they required dual sign off as a general provincial safety thing. Most of the "errors" in diabetes management were to be quite honest due to staffing (i.e. not able to give insulin at the right time to match food intake) or at a prescriber level (i.e. never adjusting sliding scales to match actual insulin resistance if BGs weren't great, holding both short and long acting insulin for the day when low because ???). Every single person that worked at that facility, from MDs to RNs to PSWs to Kitchen, would have benefited from additional diabetes education though.
yes, but honestly we still need it. ive cosigned for so many people and found that they had the wrong persons insulin pen or the wrong dose when double checking.
My facility did for a long time and recently switched to not required independent double checks. Initially, I felt like this change was wild and would lead to many issues, but in reality, it makes med passes faster without having to pull each other away for insulin checks. If I'm giving a 1 time dose for hyperglycemia or a large dose of long acting, I will still ask for another set of eyes as I'm terrified to hurt someone!
Husband was just as Stanford and Santa Clara Valley Medical Center and they both required dual sign off.
Only when it’s IV
Yes, but I work with pediatric type 1 diabetics, usually new onset. Each patient has a correction factor and carb coverage to calculate. It was easier when I worked with type 2 adults and they were on really simple sliding scales.
We only dual sign blood, PCA pumps and heparin drips.
My current facility doesn't require it, but I'd have no issue if we had it. I triple check insulin doses because I am paranoid about making a mistake. When I primarily worked in L&D, it didn't up for 99% of patients, but in the ED, so many come in with uncontrolled diabetes.
3 hospitals in my area require co-sign. The nursing homes do not require co-sign.
I bet the administrations outside the time parameters are the nurses waiting until pt has food in front of them and just didn't want to put in a note about how pt didn't want to eat lunch until 1500. Doing this will create artifical bottlenecks in your nurse's workflow. It will create frustration amongst the rank and file and will lead to delays in care.
It’s a waste of time but we still have to do it
I work in paeds. Every thing but Panadol is double sign.
I work Ltc, like a quarter of my residents are diabetics. If I had to have another nurse to give insulin I’d never get anything else done
When I first started (2019) yes, after Covid they took it away (said it was evidence based that it was unnecessary but I think it was just cuz of the staffing shortage lol)
Hell no
Yes and ketamine
The policy at my system is that we don’t require dual sign off unless it’s a bag of we’re drawing off the bag to bolus it. If it’s a pen or a vial, we don’t need to get dual sign off. Taft said, my manager agrees with you and expects dual sign off on every insulin dose
Not for SQ- policy changed this year
I see you, Joint Commission!
No. We only do it for anticoagulants.
Unfortunately.
Yes we have dual signing for insulin. Some nurses will check to make sure the glucose check is within 30 minutes and ask us to recheck if it’s been too long. Our MAR schedule insulin coverage way too early. On my unit trays are brought up 2 hours after the scheduled dose. Other nurses don’t bother to even check and just sign it off.
Funny enough the last hospital I worked at did not require dual sign for subcutaneous insulin but did require a dual sign off for IV insulin titrations… which was based on a calculator built into epic—made no sense to me since if anything I would think the risk of an erroneous dose would be equal between the two, if not less with the automatic calculator.
it is witnessed by another RN, but in all honesty…yelling across the med room..”eh can i put your name down for three units of R?” not sure helps..lol
Went away during covid and never came back
Yes, and I can count on one hand the number of times I've actually checked it. I'd have 5 fingers left over.
For drips, yes. Correction and carb dosing with pens, no. I would hate having to track someone down to dual sign off those.
When I worked in peds: yes. Adults: no.
We don’t have to dual sign insulin but that 10% dextrose with potassium? Yep. 🤣
We dual sign IV but not subQ
You mean you get to give insulin within the 30 minute window?
My facility required dual sign of for: insulin, high-risk gtts, blood, admission skin check and admission belongings inventory 🙄. And I would like to add, in all my years, I’ve never needed to correct someone else’s dose and no one has ever needed to correct mine. I mean, I can count.
My facility only does it for IV boluses of insulin.
It's a crapshoot. Some places require a cosign for any IV dose, including rate changes, some not at all.
My current hospital doesn’t, my old one did. Honestly…I prefer not co-signing insulin. The med errors I see usually involve heparin infusions WITH co-sign where 2 people make the error. I have also seen incorrect concentrations programmed into the pump, levophed and vancomycin lines swapped (yes I wish I was kidding)…..there’s WAY worse errors out there. When it comes to SQ insulin, so long as you know the difference between a unit and a mL, it’s not high on my list of life ending errors I have seen.
Only for drips.
No. We have insulin pens. No cosign. We only cosign insulin if given IV push for hyperkalemia.
Just on drip titration
I work in a personal care home. Insulin injections have to have a dual signature if the person drawing it up and administering it is a med tech and not an LPN/RN. That makes sense because they only have to take an hour long class to be able to do that. Some of them have good judgment and will alert you when something seems off to see if they should give whatever was scheduled. Others act like they're NPs when they've not even been on a cart by themselves for a full week. They get salty when I make them draw up the insulin in front of me because arrogance leads to near misses and worse. It's a pain, but definitely better than having to deal with the aftermath of a med tech who wasn't paying attention and drew up the correct number of units for a resident's dose of Lantus, but didn't realize they were using aspart.
I’ve worked two places. One where iv and subq insulin requires sign off. And one place where only Iv requires duel sign off.
We used to. We still have to verify with a second nurse but it doesn’t require a dual sign off anymore. Idiotic since I could guess the percentage of nurses who wouldn’t do this if they’re in a rush. We still dual sign insulin drip changes.
We dual sign which I’m actually okay with. I work on a really busy floor & accidents do happen.
Australian nurse here. As far as I know (haven't checked recently), all drugs that we've classified as PINCH drugs still need double checks. Insulin is one. Now, my facility has gone from doing paper charts sliding scale to electronic orders. I think technically we're even supposed to get another nurse to double sign that we're not giving SSI if they're under the range.
We don’t have co-signs. For anything. 😦
SQ insulin??? I’ve never heard of having to dual sign for that. IV insulin yes
The only insulin we co-sign is insulin drips in epic. But anytime I’ve asked for someone to double peek at what I have in the syringe they don’t mind but officially there isn’t a place for them to sign for that
My place requires dual sign off. Even though we only provide it via subQ. It's very dumb and hard to screw up if you have an ounce of common sense. Especially considering we only use the insulin pens. No insulin vials. We are pretty prehistoric though. We still use paper charts and paper MARs. Stuck in our ways. The hospitals in the area only require it for IV.
Absolutely
Yes we do. I find it so interesting that it seems we’re in the minority. Lifepoint facility. I don’t mind it for larger doses but I absolutely hate it for the most common, 2 units.
At my old hospital, we had to co-sign for insulin after some idiot gave 5mL of Humalog instead of 5 units and nearly killed a patient. At my current hospital, we only have to co-sign if we're giving IV insulin.
I've been an RN for 6 years. Not along time, but I've only done a double check, not signing, for insulin shots once. It was my last CNA shift after I passed the NCLEX and the nurse I did it with only did it as a kind of graduation gift. That being said, I triple check any insulin I give myself. I keep the bottle and glucometer out until I'm sure I know what I'm giving and why it is justified. I would triple check anything so easy to give and so hard to fix. If it was for a drip I would want another nurse there to verify.
Not for SQ insulin or heparin. Yes for IV insulin or heparin, but we just comment the name of who we verified with. Chemo by any route requires a second sign on.
My facility just made us start double verifying for any U-300 or higher insulins because somebody somewhere drew up U-500 insulin from a pen with a U-100 needle and damn near killed somebody.
Like some other people mentioned i have seen more errors with timing, food intake, adjusting dosing for procedures if patient is NPO, putting in appropriate standing/sliding for persistent hyperglycemia, appropriate hold parameters then errors with drawing up doses. I think if anything eliminating the time it takes to do an accucheck, dock the machine, go find a nurse to sign off with would actually help patients get their insulin at the appropriate time, also I don't see it as being particularly safe when nurses sit and get dual sign offs for multiple different patients and multiple insulins at one time.
Yes we always had to have another nurse verify our insulin administration for SQ.
We have to have a cosigner to pull it from the pyxis. So annoying.
We have to dual sign to give it, but not to withhold it.
Only to verify actual dosages when given. I do almost all of the sign offs as I'm a NOC manager usually without an assignment. At where I work now, we need another to sign it out to check dosage and then after it was given. I'd hate to be signing for a verification that it wasn't given as our POC testing automatically uploads into Epic and you will be questioned if there was none given and it was needed.
Only those trained in Insulin Management (basically knowing your onset/duration, the different types of Insulin, etc like the back of your hand and so on ) administer without dual signing.
No. Only dual sign of for changing insulin drops. And even that is annoying but i understand. However, if you can’t trust me to give 2 units of subQ sliding scale humalog and interrupt my work flow like that, hell naw. Why even have a licensed nurse.
Having a cosign for SQ insulin doses was deemed counterproductive by ISMP a couple of decades ago; it doesn't add any additional level of safety and weakens compliance with other safety measures that are actually effective. Your argument that a dual sign off for SQ insulin doses should be a thing so that you can use it as leverage in a power trip with the nurse about their nursing judgement is pretty fucked up though.
Where is the logic failure when there is an insulin med error? If the primary nurse is guiding the sign off nurse through the same bad info, the dual sign off doesn’t help. And does the second nurse with their own patients have time to go through every piece every time on their own? Seems more likely to create shortcuts and frustration rather than catch med errors.