Quote from mcksa
going tomorrow to face hospital personnel due to a serious med error concerning insulin-
. now i feel like i'm on the firing line (literally) and need any advice on how to get through this without totally falling apart or looking like i am unafffected - i know partially what is expected of me - and know they want a plan of action as far as what my follow up will be- not sure how to outline this- please- any help would be appreciated - i'm a veteran rn of 33 years and this is driving me crazy- but also feel very blessed that the pt . survived ny error
[font="comic sans ms"]first off, let me just reiterate what you already know. everyone makes mistakes, and anyone who tells you they've never made one is either a damned liar or too dumb to notice one.
years ago, i changed the tubings on a patient with four drips. somehow, i got the lidocaine (that alone will tell you how long ago!) and heparin mixed up. the patient kept having runs of vt, so we'd bolus with lido and turn up the drip. when i left, the "lidocaine" drip was maxed out at 4 mg./minute (60cc/hour.) we were following ptts, and the next one was due at 2000 -- right after i went off shift. it came back high, so the night nurse turned off the "heparin." meanwhile, the patient continued to have vt. not to long after mike turned off the "heparin", the "lidocaine" ran dry. at that point the mistake came to light.
i was devastated. mike had written up an incident report and turned it in (as he should have!), but i'll never know whether my nm had read it or not. mike told me at 0700 report, being quick to reassure me that the patient, while a little alarmed at his cherry red urine, had suffered no damage. i immediately went to my nm and told her about the mistake. at this point, i was a mess, crying and saying over and over again "i could have killed that nice old man. i could have killed that nice old man."
on the spot, i came up with some ways to keep from making the same mistake again and apologized over and over. when i finally wound down, i asked the nm if i was fired. "no one," she said, "could ever punish you as much as you're going to punish yourself."
in contrast, a nurse who i will call debbie (her name did start with a d) walked into a room and defibrillated a wide awake patient in sinus rhythm. she mistook artifact for vf. we've all mistaken artifact for vf, and i've seen a few people even attempt to defibrillate it over the years. none of them were fired. debbie, however, rather than being apologetic, giggled and said something to the effect of "oops! silly me!" she was gone before the end of the shift.
my point is (and you knew i had one, right?!) admit your mistake. express your sorrow that it happened, your deep regret that you made the mistake, your determination to never make another one even remotely similar and a plan for preventing it. (i'm sure you've thought of several plans for preventing it. i went over and over and over it in my head, thinking "if only i'd double checked all the lines after i was finished." "if only i'd had someone double check me." "if only i hadn't been chatting with the man's partner while i was changing lines" etc. etc. etc.) your plan doesn't have to be formal or minutely detailed, but you do want to demonstrate that you've thought of some ways to prevent this mistake.
now, take several good, deep breaths and tell yourself that you won't make this same mistake again, that you're a good nurse and a good person. i wish you the very best of luck.