I'm tired of screwing up at work

  1. 1
    Worked 7a to 7:30 p in our busy PACU today. Reported off on a vascular pt who had arrived hours earlier on a phenylepherine drip from the OR in company of both the service and anesthesia. Both said they thought he just needed to wake up more and expected him to be able to be weaned off soon. I asked what the BP goal was and service hemmed and hawed, then said how about 110 systolic, and we discussed how the point was just to keep the vasculature nice and open for the first couple of days after the surgery. A few minutes later, our charge nurse looked up orders for me (they are in a separate system than the one we chart in, and we can't access the order system from the computers in our recovery bays - it sounds insane as I write it, but that's how we work). She wrote everything down (e.g. IVF orders, lab orders, etc), including an ordered MAP goal of 80-90 (that's more like it).

    I wasn't able to wean him off, and he couldn't go to the floor with the drip. At 7:15, I reported off to the nurse who was taking over, we could take him to an obs unit if we could get the rate to 50 mcg/min or lower, left her my phone number to call if she had any questions. About 10:00p, I check my phone, see she had called at 8:00 (doh!) asking where the order for the phenylepherine was...Didn't even think of it. Double-doh! I think that when I got the list of orders from the charge nurse and it said MAP goal of 80-90, I translated that into a phenylepherine order in my head. But now I'm at home and I don't know for sure that there was a proper order in the orders computer, and I have no way to check (so I can sleep tonight).

    On the one hand, I know there was no question that the service both knew that the neo was running and wanted it running, so getting the order in arrears would not have been a problem for the nurse who relieved me, if there was not an order in the computer. On the other hand, dang! I ran a neo drip without knowing I had an active order! How did I miss that?! I know that the way we have things set up is asking for trouble - we have some orders hand-written in the chart, and we have other orders on a computer that we can't access without going to the charge desk, and because it's so inconvenient to do that when you have a fresh post-op, our process is to have someone else look those orders up when the pt arrives and jot down any relevant orders on a sticky note for us - it's a miracle screw-ups don't happen all the time, and for all I know, they do. Still. It feels like such a rookie mistake. Last week, I mislabeled a lab specimen. I won't drag you all through that one too, but it was a similar situation where someone else was helping me and in that case, handed me a string of 8 or 9 lab labels, one of which was not for my patient, and I didn't catch it, which I should have. In the ideal nursing school world, all of this gets caught, i do all my checks every time, but there always seems to be so much chaos all around, and lately I feel like there's something stupid I do like this on every shift. Is it just a streak? If so, is it almost over? Anyone? Because I've had enough!

    Thank you, kind (I hope) allnurses. I feel better already :-)

    Post-script: I just called PACU to sniff out if anyone knew what the deal was, how it was resolved. I didn't do that initially because I didn't want to draw attention to my mistake, as I knew it was already being addressed. My patient was still there, no surprise to me. I asked to talk to whoever was taking care of him. She was clearly super busy and had no idea what I was talking about, so that was some relief. (No one in report told her, "You wouldn't believe what Bubblehead, RN, did!") Of note, she is the 4th RN he's had in PACU. I left at 7:30, it's now 11:15, and he's had 3 hand-offs in that time. I would ask for your prayers that there actually was a neo order in the computer, but what's done is done and no one's prayers can change it now. Maybe say a prayer that I've filled my quota of doing stupid things for this year?
    imintrouble likes this.
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  4. 20 Comments so far...

  5. 4
    why would they not transfer this pt to ICU??
    canoehead, me1989, nrsang97, and 1 other like this.
  6. 1
    I agree with Roma. This sounds like an ICU patient, why stay in PACU for the time it takes to do 3-4 handoffs? But I guess that's beside the point.... Don't worry about it. Seems like the pt got the neo ordered in ICU and for some reason that didn't get to an actual written or computer entered order...? That happens. The next nurse just needs to call for an actual order.
    nrsang97 likes this.
  7. 1
    The neo was actually started in the OR, but you have the idea, it was obviously something the service wanted, and they didn't need a written order at the time it was initiated because it was in the OR, but they should have provided (and I should have ensured they provided) a proper written order once they were out of the confines of the OR environment and it was to be left running.

    I kept him in the PACU for a few hours (3 hours, during which time the RN in the bays next to mine had a patient code, so there was some time lost there helping her) trying to wean him off before deciding it was not going to happen anytime soon. I thought the MD would say to send him to our short-stay post-op ICU (which is where I usually work - I was floated today). When I called the MD and told him we were unable to wean so we couldn't send him to the vascular obs unit at he was slated for, he said that wasn't true, the chief of the service "e-mailed everyone" two weeks ago that they could take pts on drips, so I said great, wish I knew that three hours ago. My charge called the obs unit to confirm, we found out he was partly right; they would take a pt on neo but at no more than 50 mcg/min (he was at 67 at the time and shortly after I had to bump him to 75). Shortly after, I reported off because my shift was ending.

    When I called tonight to see what the status was, I was so sure that he would already have been transferred to the short-stay post-op ICU that I called there first. When he wasn't there I thought well maybe they did get it down. I didn't know the number for the obs unit, plusi figured ey wouldnt have the skinny on what i wanted to know anyway, so I called PACU and was very surprised that he was still there. Those three hand-offs were probably the reason; probably no one had the time to initiate getting him in the right place before they had to hand him off again. What's so funny is that his then-current nurse was so busy she could barely talk to me, I'm thinking, why do you still even have this guy? They have two nurses and two pts upstairs, ship his arse up there and get him out of your hair!

    BTW, we have a lot of staggered shifts in our PACU, so some people leave at 7:30, some 8:30, some 9:30, some 10:30. I know when I reported off, my charge had already left and someone else was in charge (we consolidate all of our areas around 7:00 - it's really pretty massive, 80 cases is a slow day for us). I thought one gal was going to be his RN, started to report, New Charge busted in and said, no report to Other Gal, we'll have him out of here by 8:30 (Other Gal got off at 8:30). I'm thinking she must not realize we've tried to wean and can't so I started to explain and she cut me off, "I know, I know, Day Charge told me all about it." Which, to me, says that she didn't think there was any weaning issue at all but rather I'm a slow nurse because I'm floating and I just wanted to hang onto a patient so I couldn't get a new one, and The Real PACU nurses would take care of business and get him to the floor. It's true that I'm slower than those who actually work there, but who isn't when they float? And I'm always very helpful to my fellow RNs while I'm there. I guess I have the mild satisfaction of knowing she was proven wrong, if she was saying what I think she meant. She's normally very nice, that was an exceptionally catty thing for her to say, so I don't know if she was having a bad day or if I misinterpreted.

    I feel a hundred times better. Thanks for reading my many words and using your few to talk me off the ledge :-)
    Esme12 likes this.
  8. 8
    This is a classic example of why incident reports should be completed. There are clearly root cause analysis issues here with the computer system and how orders are being processed and communicated. These problems are bigger than the individual nurses. I would encourage you to document this because the next time this happens the outcome might not be as favorable.
    AJJKRN, LakeEmerald, salvadordolly, and 5 others like this.
  9. 1
    I have my streaks of scew ups too, don't feel bad. It happens.
    4_Sq likes this.
  10. 6
    Definitely make time to discuss this entire scenario with the risk management nurse. This whole system looks like more disasters waiting to happen.
    4_Sq, sharpeimom, canoehead, and 3 others like this.
  11. 6
    Since you received the patient from OR, already on the drip, then you HAD an order; it simply needed to be written or placed in the computer. Sometimes I think our computer charting makes it easier to make mistakes. Before computer orders, we walked around with the doctor and wrote down orders as he/she talked. I have worked with doctors who never wrote anything, they expected you to listen to them and write the orders. It is ridiculous that you can't access computer orders in the recovery bay; you probably would have noticed the neo was not there, and could have rectified it.
    4_Sq, FLArn, LakeEmerald, and 3 others like this.
  12. 2
    I agree with TakeTwoAspirin - this situation warrants some sort of formalized follow up. If your organization has a 'near miss' report or something similar, this would be appropriate, because it appears that the issue may have been a failure to communicate. The fact that you have to deal with two separate charting systems is ludicrous!!! The only thing standing between serious errors and the poor patient are the harried and stressed-out nursing staff. Not acceptable.

    Without some sort of formal documentation, these sorts of issues are never resolved. Near misses are just as important as the more serious incidents because they highlight organizational and process problems that may not be apparent any other way. Of course - in order to be really effective, the organization MUST take a non-punitive approach to dealing with 'human error'. We all make mistakes.
    canoehead and sallyrnrrt like this.
  13. 0
    Agreed! Thank you for the replies!


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