[My2Giants]

Hi Julie,

Have not seen any new post from you so I just wanted to let you know that I am thinking of you and sending prayers your way. I pray for your comfort and peace during this time. We are here for you if you need to talk.


nd_mom

[zaleah]

I too have made errors. In 15 years I have made 2 significant (sp) errors that were potentially deadly. The first actually ended up benifitting the patient. I work ED and was fighting with the internal med team to intubate and sedate a very sick septic pt, they did not want to as he was 'not an ICU candidate', I got mad and finally said "you have got to at least sedate him--he is going to fall off the bed and he is ripping his lines out." They ordered 20mg of Valium (hx of etoh abuse) I thought they meant IV, they meant IM. I gave 10mg, waited 10 min and gave the 2nd 10 mg. As the team rounded on the pt he resp arrested. The attending was not pleased, they were forced to intubate, the ICU guy was livid, but the man got appropriate care, I just got the greif.
The second was not so good for the pt. A very anxious mother and daughter team, the Mom had a picc line for chemo--they were harrassing us all day for minor stuff, and I cannot even remember why she was there, "she is near someone coughing", "the sheets have a spot", "was this room cleaned properly", etc..... Mom finally got her get out of the ED card and I went to D/C her picc and flush her line so she could go.
I grabbed the heparin and a 10cc syringe and ran in so I could get rid of these pains in the )&*&(. As I slammed the syringe full of fluid in, I realized what I had just done---flushed the line with 10cc of 10,000u/ml of heparin. I was freaked.
The doc on was surpizingly wonderful--he has a reputation of not caring about anyone but himself, but let me tell you, he sure went to bat for me. He called hemetology to find out if we should give the antidote for heparin (that my brain cells are blanking on right now cause we never use it) and they said no, just moniter as there are too many side effects. I went to the Mom and Daughter team and explained everything and apologized. Lots of tears, and the daughter went nuts--unitl she realized Mom was now going to be admitted for observation. I followed the pt, and her clotting times did not come down for over 5 days--they should have been down the next day!!! I lived on egg shells!!
Mistakes happen, we are busy ----WE ARE HUMAN!!!!!!!!!!!!! Is your work supporting you, are your collgues and manager behind you? What about the docs? Is there an internal support phone line?
You are right we need a support group--if either of those pts died because of me I would be freaked out, but looking back on my 2 near misses I realize there are system errors that also occured and my shoulders need not be that broad. NOR DO YOURS. You are a good nurse, and as everyone else has said--think of the good you have done.
Could you start a thread "What is you worst med error?" some version of a support group? it is all annonymous right? Are we not supposed to be learning rather then blaming?

[anne74]

My heart goes out to you. I could just have easily made the same error, as could many other nurses. I've had my share of med errors too. We work in a fast food pace, but unfortunately if we make an error it can have serious consequences - sometimes, I feel like we're set up to fail in such a chaotic environment.

Often a mistake cannot be attributed to any one person - it's often a system of errors, and since the poor nurse is the last checkpoint to the patient, we take the flack.

If you've only had one error in 15 years, then you're amazing. Don't beat yourself up about it. You obviously didn't mean to do it, as you've already dedicated your life to helping others, and you've done just that for probably thousands of patients.

Best of luck to you. Try to remember the number of those you've helped. You'll get through this.

[NREMT-P/RN]

I will hold you in my prayers. I can not imagine what you are going through and the range of emotions that you must be feeling. I hope that even in the absence of support from others that have "done the exact same thing", you will find support from many others! I know that there are EAP programs and counselors that do specialize in the treatment of medical professionals. Please find someone that you can, in confidence, talk with at this tragic time.

I think we have all made a medication error at some time in our career, if we have been at this for any time. If there are some who haven't made a mistake, it is likely that they will at some point in their career. Medication errors are system failures, it is just unimaginable that you are taking the entire blame. The patient is not the sole victim here.

You are not alone. My heart just breaks for you. The exact nature of your error is less important than the end consequence and we all must recognize "but for the grace of God, go I". I recognize that I am not immune from error.

Yes, there are going to be things that must be worked through - many unpleasant and emotional. Care for yourself, surround yourself with family/friends and those whom care about you. This, although tragic, is ONE mistake. It is hard to keep perspective with your eyes full of tears, but your life depends on it. If you are feeling unsafe you must call for immediate help at once.

May God bless, protect and care for you.

[VegRN]

Hi Julie,
The med error that you are talking about, "went to hang pcn but it was another drug", sounds like what happened at one of the other hospitals in my town. Let me tell you, we have talked about this on our unit over and over, you are in all of out thoughts and prayers. Our heart goes out to you and we don't blame you, If I could tell you how many times I have heard fellow nurses say, "that could have been any of us". And let me tell you, there are so many factors involved in a med error, it's a system problem, I'm sure it feels like a personal one though. I hope you get the support you need.
Take care.

[Bill Levinson]

Originally Posted by augigi

In my graduate year as an RN, I was placed in the ICU for a rotation. After one month there, I administered potassium chloride into a burette and set the drip rate for one hour infusion. Unfortunately, when I returned to check it in 10 minutes, the entire infusion had run through, due to a malfunctioning IV roller clamp set.

This was not your fault. Speaking as a quality engineer (I am not a medical professional), it is evident to me from what you have written that unreliable equipment was to blame. I am surprised that the family did not sue the equipment manufacturer.

How would I handle this? There are plenty of commercially-available flow monitoring devices. If you set the drip rate for a one-hour infusion and the meter detects a flow rate that will result in delivery of the entire dose in ten minutes (i.e. it is running six times as fast as you set it), an alarm should sound and the flow should shut down immediately.

The person who started the thread wrote,

"i hung a med that looked like pcn, but was not. it was a cardiac toxic drug and resulted in the almost immediate death of my beautiful pt,"

All right, how did the mix-up occur? Two drugs whose packaging looks similar sound like a mistake that is waiting for a place to happen. I need more detail to understand this but I'm pretty sure that this could not have happened under any decent quality management system.

[Bill Levinson]

Originally Posted by VegRN

Hi Julie,
The med error that you are talking about, "went to hang pcn but it was another drug", sounds like what happened at one of the other hospitals in my town.

In other words, the hospitals do not have anything that resembles the kind of quality systems we use in industry, where errors like this are pretty much impossible. (If they happen, they don't happen more than once because we fix the underlying root cause.)

Factories process thousands or even millions of "widgets," from multiple product families. Each requires different processes and process recipes. Widgets don't get the wrong processes (~ wrong meds, wrong operations) because we have traceability systems and production tracking systems.

We also have safety systems. As an example, it was possible to hang the wrong drug on an IV unit but it is not possible to connect a hydrogen line to an oxygen tank (or vice versa). The connections are designed to be incompatible because connecting oxygen to a line that contains hydrogen, or vice versa, can cause an explosion.

If you give me five malpractice cases, or five cases in which a nurse is "written up" for making a mistake, I can probably show in at least four cases why the hospital administrator(s) and not the doctor or nurse should be disciplined or even let go.

[Bikechicky]

Julie,
I made a serious med error once, by the grace of God it did not result in death. I was assisting a resident placing a central line and handed him a syringe filled with lidocaine instead of saline for a flush, then heard the words we all dred from the patient "I don't feel good"... she went into a temporary cardiac block and recovered, the doctors were very supportive. I was a wreck, I seriously considered quitting nursing for a long time, my hands trembled when I did meds for awhile. I talked it over with close friends (not nurses). I finally found forgiveness from one of my close friends, who basically told me "how could I as a nurse expect to never make a mistake!" He is right, as nurses we expect that we will never make a mistake, it is not in our culture, we have no avenues to help us deal with the fact that we are human and we will make mistakes. I think doctors are taught that some of their patients will die as a result of their mistakes, they seem to be able to handle it better than we do as nurses.

I think this is an important line of discussion. I decided to continue in nursing and I learned that ALL of us can make a mistake, and it has made me a better nurse, I always give myself the extra time to double and triple check my meds, I have never forgotten that mistake and the lesson that I learned.

I hope you are able to find support, and forgiveness and stay in nursing, we need you.

[indigo girl]

Julie, I am so sorry for your pain, and for what happened. Listen, to what Bill Levinson is saying in his posts because it makes good sense. You are a good and loving person. The system failed you and your patient.

[Sodie]

I have made mistakes too. Fortunately, I have not made one that resulted in a sentinal event. I did have a patient respond to a med (the wrong one) that I administered one time. Fortunately, the MD was present and ordered a reversal drug to help minimize the problem. The patient suffered no ill effects. Even though things turned out well for the patient and myself, I will never forget it. You learn from the mistakes.

You are right, things will not be the same again. You will check your meds and recheck your meds when you hang them.