Time Management

Lev, MSN, RN, NP · Dec 10, 2013

Hello everyone,
I just graduated from my program and have been doing my final placement for the past 6 weeks on a very busy surgical/trauma unit which I've been loving. I thought I was doing very well and keeping up, and up until last week I was taking a partial assignment. This week my preceptor gave me her full assignment as I need to be able to handle it before the placement is finished. These past 3 days have been so overwhelming I can't even describe it. I feel slow, incompetent and that my preceptor is frustrated with me (although she is amazing and very nice, I can just tell)

Totally normal feeling to have in that situation...it's a transition period.

I have always been very good at triple checking things and doing everything that needs to be done...but on Saturday I made my first medication error. The patient was a diabetic and I checked her sugar in the morning which was high, over 20. I told my preceptor and we told the Dr, who wasnt too concerned and just told me to give 12u of her insulin - which I did. Checked it at lunch...sugars were 26. Residents were in the OR so they were unreachable for a good part of the day...but gave another 12u of insulin as per my preceptor's direction. She was on CF diet so not eating a whole lot. So the residents get back and we're trying to figure out what is going on with the sugars...I double check my MAR like I always do to make sure I gave everything and realized that under the sliding scale in the MAR there was an order to give 44u of a different kind of insulin in the morning, which I missed and didn't give.

I figure you mean the sugar was first over 200 and then over 260. Were the two sets of 12 units you gave a short acting insulin on a sliding scale like Novolog and the 44 units you forgot to give a longer acting insulin such as Lantus? If so, the long acting insulin would not have made *such* a big difference in her sugars from morning to lunchtime. It does not have a peak. You can think of it like an extended release tablet that releases a small amount of medication every hour. It is a mistake and you will learn from it and be more careful.

I find it easy to miss medications there because on the MAR it says "see diabetic profile" beside all insulins and diabetic meds...so none of them are signed for right there. Anyway my stomach sank, I told my preceptor right away and we told the MD. I bawled my eyes out right in front of my preceptor because I was so upset at this error and felt so incompetent. She reassured me that mistakes happen and that I just need to learn from it so it doesnt happen again. I come in the next morning to find out that patient fell on nightshift while walking to the bathroom and had an MI...and she is now in stepdown. I can't help but think that it was my fault because her sugars were high...my preceptor assures me that it probably has little to do with that and there are other factors but i still feel terrible.

Her fall and MI had probably nothing to do with the sugar. In fact the fall was very likely a result of the MI.

Yesterday we had 5 pts and 4 were total care. I just felt so slow, and my preceptor did care on 2 of them....I just thought to myself, what will happen when I'm on my own, and I don't have a preceptor to help me? How could I handle this type of assignment on my own? Even with her doing care on 2 of them, AND my evening meds for me...I barely got everything done on time.

Ahh, but you still got everything done on time. That is an accomplishment. Barely getting it done is still getting it done and is much better than not getting it done. :)

I need time management tips...and prioritizing tips. Ive been going through this site looking at the other threads on this and I've gotten some helpful advise. I've also ordered a book on critical thinking and clinical judgement to help with that, as I feel I am lacking in that area.

Arrive early. Take it one step at a time. Be prepared with everything you need before you go in the room. Pull meds at the beginning of the shift and keep them in the drawer. Anticipate pain medication needs. Get an extra bag of IV fluids for each patient and put in the drawer at the beginning of the shift. DELEGATE. Cannot say it louder! Use your resources. Master the 5 minute, yet thorough assessment. Practice it on your friends. Head to toe is not always the quickest way to go. Sometimes you have to start at the feet, if the patient is taking their meds by mouth. I'm attaching a word document with a list of time management tips I compiled for myself.

My evaluation from my preceptor was good, and I really want a job on this unit. I just hope I didn't ruin my chances with that error.

I hope so too, but don't beat yourself up. It's a rookie error and you didn't kill anyone. In fact you recognized your mistake. PS a blood sugar in the 200s, while high, is not critical. You will learn what you can manage on your own and what should be reported right away.

Time management tips.doc

vintage_RN, BSN, RN · Dec 10, 2013

Thank you very much for your reply, it's very helpful. I will certainly use your tips. I'm in Canada, and we measure sugars a different way...like 7.7, 10.1, 20.5....etc etc. Not sure the units of measurement.

Lev, MSN, RN, NP · Dec 10, 2013

Thank you very much for your reply, it's very helpful. I will certainly use your tips. I'm in Canada, and we measure sugars a different way...like 7.7, 10.1, 20.5....etc etc. Not sure the units of measurement.

Ohhh, so you really meant 20 and 26....What is considered a critical value? (Low and high)

chrisrn24 · Dec 10, 2013

Google blood sugar chart Canada. I guess a blood sugar of 20 in Canada is a blood sugar of 360 here in the States. 26 in Canada is like the high 400s here.

OP I don't think your mistake contributed to the fall and MI. I mean I don't know the whole pathology but I don't think they are related.

I have patients who I've never seen have a sugar below 250 (13.9 in Canada) and acutely they are fine.

vintage_RN, BSN, RN · Dec 10, 2013

OK in Canada we measure it mmol/L where in the states its mg/dL......I haven't seen levels that high very often but the physician wasn't too concerned about it.

Definitely something I won't do again.

SleeepyRN · Dec 10, 2013

Awesome feedback Lev. And OP...I see a caring, competent nurse in the making. :-) Hold your head high :-)

Roy Fokker, BSN, RN · Dec 11, 2013

Her fall and MI had probably nothing to do with the sugar. In fact the fall was very likely a result of the MI.

Agreed! Although there is the chance that hypoglycemia could be a possible culprit - given how the sugars were running I very much doubt that.

Ahh but you still got everything done on time. That is an accomplishment. Barely getting it done is still getting it done and is much better than not getting it done. :)[/i']

Bless you! And my first nursing preceptor who kept trying to tell me this but I kept feeling like a failure because "I didn't get everything done like I wanted to". It took me a year into my first job post-school to realise that nursing is a 24 hour profession and that some days no matter how hard you try, you won't get to do everything to your satisfaction.

DELEGATE. Cannot say it louder! Use your resources.

To the OP -- And when in doubt or you feel like you're drowning - PLEASE ask for help from your colleagues. Don't worry about the "impression it might give". That you can't "handle it" or whatever! Always remember, it's not about you, it's about the patient. As time goes by you'll recognise that even veteran nurses sometimes ask their colleagues for help. There's nothing wrong about it. It doesn't make you a 'weak nurse'. It's just the nature of the profession. I'd rather have a colleague recogise they are drowning and ask for help than keep trying to soldier on and render sub-par or unsafe care to their patients.

I've said it before and I'll say it again: "Good judgement comes from experience. Experience comes from a lot of bad judgement". You are after all a new nurse. It WILL take time for you to come to grips and come up to speed. When you've bonded with some of your more veteran colleagues on the unit, ask them and they'll tell you their own stories - in other words, you're not alone; we've ALL gone through similar things in our own pasts. :-)

If you want to read (one of) my stories (and not be bored by it!): https://allnurses.com/general-nursing-discussion/med-errors-share-370373-page3.html#post3440166

I hope so too but don't beat yourself up. It's a rookie error and you didn't kill anyone. In fact you recognized your mistake. PS a blood sugar in the 200s, while high, is not critical. You will learn what you can manage on your own and what should be reported right away. [/i']

To the OP - Absolutely! This is fantastic advice right here - to err is human. And as you gain more experience, you'll even gain insight into managing changes in your patient condition - both critical and non-critical.

Chin up and keep plugging away!

cheers,