Quote from NurseNicoleRN
.i just feel soooo bad i keep replaying it in my mind and wondering how i could have missed it ......i know i was busy but its no exscuse.......i want to get over this but im having a hard time....am i a horrible nurse......please help i feel horrible
Current thinking regarding mistakes is that they should be looked at as systems failures, not just the failure of one person. That doesn't mean that each and every person shouldn't look at the role he/she played, but there is usually a problem that goes far beyond one person making a mistake. In the case it sounds to me like you were overloaded with patients and distracted. The tech didn't notify you. The computer system didn't flash an alert when a high hr was entered.
See what I mean?
Learn your own lesson from what happened (I'll bet you'll be doubly vigilant with your postops from now on), but don't let anyone dare to "yell" at you or make you feel like you are a bad nurse. EVERY human being makes mistakes, including the doctor who is so mad.
No one comes to work intending to harm another. We are, however, all players in an imperfect and complex system. Almost by definition, these systems predispose patients to medical errors. Only by fundamentally changing the underlying systems can we get to the root of the problem and prevent future errors.
-Marlene Miller, M.D., M.Sc., Director of Quality and Safety Initiatives, Johns Hopkins Children's Center