med error!!!

Nurses General Nursing

Published

I feel like the biggest failure.

I'm a new grad RN who has been on my own for about 2 months now. I had a 6 week orientation prior to being on my own. I'm on an incredibly busy med-tele floor. And today I made my first error--a HUGE error at that. My patient was to receive a blood transfusion. He was a very sick patient who had 4 channels running with antibiotics, fluids, electrolytes, and blood. I accidentally let the blood transfusion run too long. I can't believe I let this happen. When I looked at the order I thought it was for 4 hours. However, the order was actually for 3 HOURS. And then, around 6:30 right before shift change I was told I had to transfer the patient to a different floor and my charge nurse was very adamant that it needed to be done ASAP. Around that same time I was trying to pass medications and another nurse called to ask if I can switch shifts with her and when I told her it wasn't a good time she got the charge nurse on the phone who kept trying to talk to me about scheduling and me switching shifts with the other nurse. I told her I hadn't even had a chance to sit down all day and chart, let alone look at what my schedule is, and that I would let her know later, but she just kept trying to fix up my schedule. At the same time I had a discharge who had been waiting all day to leave, a patient who needed to be cleaned up, meds to pass, and had to transfer this patient upstairs. I called report and transferred the patient and never turned off the blood. I didn't even know what I had done until the nurse from the other floor called me an hour later and said I had made a huge mistake. Not only was I supposed to have turned off the blood at 6:30, it had run up to 7:50. It ran for 4 HOURS AND 20 MINUTES. I notified my charge nurse right away and called the doctor, and we had to write an incident report. I can't believe I made such a big mistake. I'm crying and so angry at myself for missing something so big. We are so busy on our floor with so many things going on at once, it feels like I'm being pulled in so many directions and I can't keep track of everything. However, there is no excuse. This was MY fault and no one else's. I should have been paying more attention, I shouldn't have let this happen. I don't know what to do. I don't wanna go back to work, I don't want to show my face again.

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Ok, disclaimer here as an LPN I don't run blood, however, I would see what your policy is on blood--I was under the impression that 4 hours is the max time. I would be more concerned if you ran it over an hour and there was a reaction or pulmonary issues requiring Lasix between bags or some other thing regarding running blood too fast.

There is such a thing as too slow, however, if 4 hours is your max time, then yes, you may have gone some minutes over that which would require an incident report.

But in re-reading your post, if the nurse in question called you an HOUR later, and the blood had now been going for 4 hours or more than I would think that on her initial assessment of this patient then she would have noticed this within the 3 hour time frame. Now she is blaming you? WELL, seems to me that you did your thing--she should have done hers. And if you had turned off the blood, that would have added even more time to the infusion. (perhaps the 20 minutes and you DID in fact stop the blood?)

Going forward, the only thing you can do is to be sure that when you transfer a patient that the nurse gets a full report, and that you both are looking at the multiple stuff that is happening with the IV's....

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O do try to be more kind to yourself, or you won't last long in this profession. You are learning, working very hard, and did the honorable thing once you understood the mistake you had made. Therefore, you have nothing to be ashamed about nor to run away from. EVERYONE makes mistakes, no matter how careful, brilliant, and experienced they may seem at the moment (or even project themselves to be). Please keep that in mind when you are mercilessly corrected as well. The person confronting you is just as guilty of errors. It comes with the turf. Fortunately, as blistering as these experiences are, they can be excellent teachers, and thinking through how you might handle the situation differently the next time something similar occurs *will* make you stronger and better. Talking through the scenario with a trusted nurse friend may also lend additional useful insights.

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Thank you for replying. I think you're right, I did run it too slow and I was paying more attention to the IV beeping than the time. I was taught to run blood at 50 cc/hr initially, and I think I kept it at that the entire time. 4 hours is, in fact, the maximum for our hospital. I agree, I will pay more attention next time I transfer a patient, or anytime I run any blood. I will never make this mistake again.

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O do try to be more kind to yourself, or you won't last long in this profession. You are learning, working very hard, and did the honorable thing once you understood the mistake you had made. Therefore, you have nothing to be ashamed about nor to run away from. EVERYONE makes mistakes, no matter how careful, brilliant, and experienced they may seem at the moment (or even project themselves to be). Please keep that in mind when you are mercilessly corrected as well. The person confronting you is just as guilty of errors. It comes with the turf. Fortunately, as blistering as these experiences are, they can be excellent teachers, and thinking through how you might handle the situation differently the next time something similar occurs *will* make you stronger and better. Talking through the scenario with a trusted nurse friend may also lend additional useful insights.

Thank you for being kind. I'm always very hard on myself, but this time it was for good reason. I will learn from it and move on. I agree that the other nurse was guilty as well, but as a new grad I don't like to start trouble with veteran nurses. I will definitely never make this mistake again and will triple check everything before doing blood ever again. I did actually speak with a mentor nurse on the unit who really calmed me down, but I just can't help but feel like an absolute failure. I hope this feeling passes.

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Specializes in Psych, Corrections, Med-Surg, Ambulatory.

Personally, I don't think it was that huge a mistake. The standard used to be 4 hours, and the receiving nurse didn't notice the red bag and check the orders? And you're swamped, but instead of offering you help, the charge nurse is bugging you about a schedule change? It's NOT nobody's fault but yours; it's a lot of people's fault.

I admire you for taking responsibility, but I can see some clear contributors that are not of your making. They threw you in at the deep end. You will learn to swim well (I'm sorry I talk in cliches; it's how my brain works) but you will occasionally feel like you are drowning. Next time someone bugs you about stupid stuff when you are busy, think of something to ask them to do for you. Maybe they'll even do it and make your life easier. Hopefully at least they'll learn to leave you alone.

Hang in there.

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Your charge interrupted and distracted a brand new nurse in the middle of a shift to haggle over a schedule change?

My big med error almost mirrored yours. I was 22, brand new and it involved a transfusion. Nothing like it ever happened again and I did go on to be a good nurse, and enjoy my career.

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As a new RN myself, (1 year, but still considered new!) I think you were definitely left out by yourself when you shouldn't have been. In that case, I mean your charge either should have helped you discharge that other pt or pass some meds. Anything little to help. It's okay to reach out for help especially with something that complex for being a new grad of 2 months. Don't be so hard on yourself. This is preparing you for another time and another time will prepare you for a different time. We're always learning and we're always changing. We make mistakes, as long as we learn from them.

keep your head up. You are NOT stupid.

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Specializes in Oncology.

I'm very confused. Was the patient not supposed to get the whole unit? If you wanted the whole unit anyway, and you weren't trying to do 1 hour units or something for severe GI bleeding, this is a minute mistake at worst. The other nurse was probably just making an issue over it because now she had to take the unit down. Our units of blood are not exactly uniform volumes, so we can't give them over an exact time frame. I'm surprised the doctor didn't laugh when you called to report this error.

I suspect you need to learn to delegate a bit and take a firm but respectful tone of voice to survive a unit like this. I'm not sure why your patient was being transferred and why the charge nurse wanted it done ASAP. Was it increased acuity to a higher level of care? Then get it done- less of your plate. Something else? It can wait a bit and your charge nurse can do it herself if she feels it's some important. I'm not sure if your charge nurse takes their own full assignment or how much is on their own plate. Now- scheduling issues? Not even on my mind- that's where your firm but respectful tone comes in. Cleaning a patient up? Do you have aids?

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" I didn't even know what I had done until the nurse from the other floor called me an hour later and said I had made a huge mistake. " Fascinating that the accepting nurse had the time to call you that the blood administration took too long. Your patient was transferred to a higher level of care during the transfusion. I am sure you included in your report that the patient was being transfused.

The accepting nurse.. is also responsible for the care of the patient during a transfusion.

Blood is good for four hours. If I had received the patient.. I would have discontinued the administration.. and called it done.

Nursing is a 24/7 job. We need to support each other, instead of writing each other up.

STOP beating yourself up.

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Specializes in Pediatrics Retired.

Forget about it. We've all stepped in the middle of a big pile of it. Any shift where nobody dies is a successful shift.

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Specializes in Critical Care; Cardiac; Professional Development.

This too shall pass. I made a med error in my fourth week of being on my own. The guy more than survived, he enjoyed the nap an extra dose of Norco gave him (another nurse gave him some and failed to inform me, I failed to check the computer thoroughly and the computer system didn't have an alert flag to let me know this had just been given 15 minutes ago...and of course the patient himself didn't tell me either).

Deep breath. It is going to be okay. The patient. Your career. Your job. All of it.

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