Sloppiness results in write-up

[longjourneydream]

Hell again,

If you have read my previous posts, I am a new grad in the ER since June of this year.

Yesterday I was called to my directors office, because one of the Docs had written me up.

Now that I look back on it I was being sloppy.

The patient was a chest pain, but not cardiac in nature.

Phlebo automatically went in drew labs and sent them, they were ordered by triage out front so they had been done.

I did not do an IV because in the past we give can give meds IM, and her EKG was fine and she had no cardiac hx.

Later Dr. gave me a verbal to give Toradol 30 mg, without asking the doctor the route I went to accu-dose drew up 30 mg Toradol and gave it IM, this is what we have done in the past.

He asked me if I gave the Toradol and I said yes I gave it IM, he said ,"Why does this patient not have an IV she is a chest pain?"

He said now the dose is now doubled due to it being IM it will be an

additional 30mg.

I told him it did not seem to be cardiac in nature.

He yelled and said it is either worked up as cardiac or non cardiac no exceptions! You need to know the difference.

Later I had done a triage for another nurse because she was busy.

I had failed to put in vitals, as well as spelled some of the meds wrong.

As a result the wrong route and incomplete triage was turned in to my supervisor and director and now I am on probation for 60 days. with weekly progress notes from my preceptor.

NOW,

I had asked for more time in the ER after my 12 weeks, because I was falling apart.

They have been putting me with seasoned nurses, to help me when I need it, but still have to carry a full load, but I do get help from the unit and the charge nurse.

The new plan is to have me precept with a 40+ year vet, and she is to help me with time managment, but because of being written up, I am to review all meds with her, and she is to check all my triage notes.

I am to do this for 60 days, it is a probationary period.

WHAT A LESSON!!!

I FEEL AWFUL...

I have worked with this nurse last leason and she is awsome, and is always there to help anyone in need.

They told me they are doing this to protect me.

Well I know I should have reviewed the medication route with the Dr.

That was a big mistake, and yes I will learn and never assume, and clarify with the Dr. 1st.

I do not blame the Dr. because he does not want his patients in danger, and he is also the ER director, so he has plenty of pull.

I know I can turn this into positive experience.

The Dr. has been super nice to me lately since my write up and he explains everything to me to help me with my learning experience.

Now there is no room for sloppyness, I am now under a microscope.

Any input from anyone??? :uhoh21:

[psalm, RN]

Hugs to you, it was a painful lesson, no harm done to pt. PTL. Now learn from the 60 days and you will come out wiser and stronger...and maybe TPTB will in the future work with more orientation for a nurse who asks for it...as you did.

[shanyone]

I just wanted to say that you sound like a GREAT new nurse and I wish you the best. I think it is awesome that you are taking responsibility for your own actions and trying to learn from this mistake (it sounds like your only mistake is not asking enough questions). I also think it's great that the nurses and doctors are working so hard to help you learn from this experience. I just know you'll come out on the other side with a better nursing head on your shoulders and you will be wonderful! You'll get off probation and you'll dot all your i's and cross all your t's while you're on probation. You'll get through it! Good luck!

Shannon

[yeSICU]

Have you thought about exploring other areas of nursing? I say this because it sounds like your learning style may not be compatible with the EC. You may need something slower paced so you can take it all in. You can not say that someone has chest pain that is not of a cardiac nature. The Docs diagnose. It is your job to A. Send cardiac enzymes B. MONA C. Stat EKG and D. Start an IV. You must always have access... what if he were to code and you have no access? You are fumbling around trying to start an IV and because you have no access ACLS is being stunted. It is sloppy nursing, and thats not an excuse. You can't have a sloppy day in nursing, especially when you work in EC or ICU where it is life or death for your patients.

There just simply isn't time for sloppy. I don't want to discourage you, but there is a niche in nursing for everyone and for some it takes a little longer than others to find it. Good luck with everything, and who knows, maybe you will come out of your extra orientation with a renewed sense of resolve and thoroughness.

[Noryn]

I would honestly quit, I am not saying that is the right decision but that is what I would do. I mean dont quit outright but I would find another job perhaps in an intensive care unit. Going to the ER as a new grad is extremely difficult, it was difficult for me and I had been a unit nurse for a couple of years. I always joked that it was harder to go from CCU to the ER than it was from long term care to CCU.

I dont agree with putting an IV in everyone. For one thing they hurt, do cost the patient money and also pose the risk of infection. Now sure if someone is having chest pain that could be cardiac related, put one in. But if you were reasonably sure it was non cardiac pain I dont see why you would have to put an IV in--and obviously the doctor also though it was noncardiac because Toradol is generally not given for someone having an MI. Toradol 30 mg is a common IV dose whereas 60 mg is an IM but it is soley the doctor's fault for not specifying the route. It was his verbal order and he should have said IV. If you didnt have a route you should have asked but again I dont see why nurses have to be the sole person responsible for everything. If the doctor had specified the route, it would not be an issue.

You failed to put VS in the computer and spelled some medications wrong? GIVE ME A BREAK. See, this situation is exactly one reason why many nurses are burned out and refuse to do anything extra. If you hadnt volunteered to assist your co worker you would have not gotten in trouble. So in the future remember the more you do, the more you get in trouble for. Now if you had forgot to do vital signs or had not reported an abnormality like heart rate of 150 then sure it could be a problem but forgetting to put vital signs in the computer? Come on.

Misspelling medication names can be dangerous but at the same time I have seen multiple doctors and nurses misspell some medications over the years. It would depend on the error but if you are busy and add a letter or make a simple mistake we are all humans. Again some mistakes can be very serious but I can just see a risk manager now saying, "You spelled it Coumidin, do you not realize that could kill someone?"

It is just to the point where it is ridiculous. As a new grad it is almost impossible to make the transition to the ER. Your co workers should be much more supportive, teach you, not degrade you or put you on probation if it is not necessary.

It is up to you, but I would honestly go to my nurse manager and the medical director and tell them straight up, in a respectful way that I felt this was unfair.

[longjourneydream]

Acctually in our ED the 1st thing to do is get an EKG on all CP.

If there is no hx, and Ekg is normal then no labs,just Chest x-ray.

If there is CP with hx;all cardiac protcols come into play esp, inserting IV because yes without it could cost a life.

My biggest mistake was not to consult the Dr. when in doubt, and took it upon myself to assume, that he was like another Dr. I had worked with, in the past.

I am definately going to give it a good shot, and learn from this mistake.

So far since June, I have not caused any harm to any patient so far.

12 weeks is not enough time for a new grad.

I have been told by my peers that I have been doing an excellent job.

Have you thought about exploring other areas of nursing? I say this because it sounds like your learning style may not be compatible with the EC. You may need something slower paced so you can take it all in. You can not say that someone has chest pain that is not of a cardiac nature. The Docs diagnose. It is your job to A. Send cardiac enzymes B. MONA C. Stat EKG and D. Start an IV. You must always have access... what if he were to code and you have no access? You are fumbling around trying to start an IV and because you have no access ACLS is being stunted. It is sloppy nursing, and thats not an excuse. You can't have a sloppy day in nursing, especially when you work in EC or ICU where it is life or death for your patients.

There just simply isn't time for sloppy. I don't want to discourage you, but there is a niche in nursing for everyone and for some it takes a little longer than others to find it. Good luck with everything, and who knows, maybe you will come out of your extra orientation with a renewed sense of resolve and thoroughness.

[ebear, BSN, RN]

There should be a protocol for chest pain, which includes IV to KVO until diagnostics are done.

The doc should specify route of ANY med. (toradol for chest pain??)hmmm....

You cannot assume that the symptoms are not cardiac in nature. We do not diagnose.

I think they just want you to be more careful with patient assessment and I think it is a very good idea to extend your orientation with a seasoned nurse who reviews your care.

Don't take this personally. They are protecting you, themselves and the patient.

[Noryn]

Nurses cannot diagnose but we are able to triage and use nursing judgement. Otherwise you can hire someone off the street for 6.00 an hour to do triage simply by patient complaint. The ABCs sound really good but they are an insult and often are of little use in the real world.

People focus too much on chest pain. For years this was the "classic" sign of a heart attack and gave many the impression that if they were not having crushing horrible chest pain then they were not having a heart attack. Diabetics, elderly often have non specific complaints. I cant tell you how many little old ladies came in ashen or grey in color and told me they had heartburn and when I got an EKG my own heart sank.

You have to look at the entire picture. What also complicates everything is that most physicians and ERs practice defensive medicine. With the legal climate though this is something that has to be done.

So no, not all chest pain is cardiac and likewise not all cardiac pain is in the chest. You have someone who has been coughing for 2-3 days, they are very likely to have chest pain or soreness and I see no need to put them through a cardiac work up. Injury to the chest wall muscles often causes "chest pain" and you document well, take vitals and can let the doctor make the decision what route to go down.

[bigsyis]

I think, considering some of the nightmare stories that we hear on this board about orientees and their preceptors, that your facility is doing their best to see that you make it as an ER nurse. If they didn't feel like you were worth it, they would've likely suggested a transfer by now, or been far less amenable to seeing that your orientation was extended or enhanced, the way that it has been. The ER Director must see that you have potential, or he could've made life pretty difficult for you. SO-use this as the learning experience that you already have, don't stew about it, put your head up, keep your mind and ears open, and look to the future. I think you'll do fine.

[SuesquatchRN, BSN, RN]

Well, now you know. Doesn't matter if the chest pain is from a baseball to the chest, start an IV and treat as cardiac.

And I agree that you're in a good place to learn, and that you sound conscientious and as if you'll do just fine.

[sharona97, BSN, RN]

It sounds like you are very open to criticism and use it to learn! Good for you, your attitude will carry you far into a great career! Best of luck.

[luv your nurse, RN]

Noryn,

Why would you advice someone to quit after one hard shift? And to go from ED to ICU because going to ED as a new grad is hard, well in my opinion going into ICU as a new grad is even more challenging! There were lessons to be learned here and should not be overlooked, giving the medication using the 5 rights, assuring an access (IV) for emergency situation, spelling medications correctly and time management. and it seems that cweeks has identified and learned from her experience and will continue to learn and do well. Cweeks- dont quit hang in there, it gets better!

"So in the future remember the more you do, the more you get in trouble for." - I disagree, we should all be helping one another as a team.