S. O. S.

[shavsha]

For the first time since I started nursing (I graduated last June) I feel really discouraged with myself. It all started last week. I made a med error. I was waiting and waiting for a now order to come from pharmacy...also waiting for the chart to come back from the unit secretaries...I gave the med iI "thought" was prescribed and low and behold it was the wrong dosage. Called the doc...no adverse effects...felt really stupid and humiliated. ( I mean the three med checks are basic and I ALWAYS do them. I don't know why I didn't think to just wait and do it properly I had an IV site that was looking bad and leaking and I was to hang Vancomyacin. I was uncomfortable with Vanco going into that vein so had the CCU nurse come and try to start him (he had a reputation of being a very hard start and I am relatively new so I deferred to her) She tried twice and could not get it and said "His veins are shot...they are all scarred" So I called the doc and got one of his ATB's PO and took a telephone order to hold the vanco. When the night crew came on there was a cracker jack RN who had served in the army and low and behold he started it..."Yeah". It was the end of my shift so I left. The next morning I get a call wondering why the vanco order read "hold" and why the orders where never noted....I assumed the night nurse would have handled things. ALSO that same night I had a lady who passed away (expected) This was my first death so I cleaned the body, comforted the family, called the mortuary and asked my charge what else to do. She said I had to fill out this paper which I did and the morturary guy came and picked up the body. Then I got a call from the supervisor...I did not contact the doctor... BIG MISTAKE! It may sound silly but I really did not know I was suppose to call him. In twenty-twenty hindsight it makes a lot of sense. (Now I am feeling really stupid and humiliated.) THEN LAST NIGHT...my first night back ...everything smooth...after report the night charge came out and said "That sliding scale insulin report should have been "BLAH BLAH BLAH" Dr. so and so has terrible handwriting...I know because we discussed it with Days , they had a question too. This insulin dose seemed a little off for the BS (that should have been a red flag right there ) but I double checked it with another RN as is our policy and I also asked the patient about it and she said "That's right - my doctor and I are right on top of my diabetes" No clarification order had been written even thought there had been questions but the bottom line is that I SHOULD HAVE QUESTIONED IT...again, no harm came to the patient. At peak her BS was still 130. Again 20-20 hindsight...I was lulled by this patient's very hands-on management of her diabetes and the fact that the order looked clear to me. So, I filled out an UNUSUAL OCCURANCE report AGAIN. The second in as many days. I know I am a new nurse. I expect to have a growth curve but I FEEL SO DOWN and am beginning to wonder If I lack judgement. I did very well in school and had excellent recommendations and a very positive preceptorship and now I feel like I will be considered incompetent...or maybe I should find some other area of nursing that doesn't have so much stress. PLEASE....sister and brother nurses.... I need perspective.

[live4today, RN]

Hi Brownms46! Our similarities are too surreal to be true, aren't they? Mindblowing, indeed! :chuckle

Hi mattsmom81! :) You couldn't be more right in saying nurses need to slow it down, and take the time to be more accurate, especially in light of how "busy" nurses are today with the way they are working under such stressful conditions. Here I am trying to return to nursing after a five year sabbatical, and I'm concerned about re-entering under the present conditions myself.

I've had such a wonderful experience in nursing in prior years, and I would hate to ruin that beautiful memory by returning only to face a much more stressed environment than ever.

We all need to pray for health care to change for the "BEST", not just the "better".

I am sooooooo "anti-HMO" that I wish Prez Bush would do something with them. They have far too much control over our health care system. It's making me think that our health care system has been turned over into the hands of 'COMMUNIST' to manage!

How do some of you view HMOs today and how they are affecting patient healthcare? Or, is that another thread???

[Brownms46]

One other thing Renee....as to your question about whether I would have noticed the different. I'm sorry to say I probably wouldn't have on that evening I made the error. I wasn't looking! I looked in the cart and saw the box of Demerol, but reached in and got the Diluadid instead! This happened...one year after graduating. The day after I finished school.... I started in NICU....and crossed trained in L&D. One year later went to a med-surg floor as agency, after not having set foot on a M/S floor since clinicals....and this is when I made the error.

RNPD

Yes...I noticed in your post that you stated up to 4mg/ml...after I went back to read over what I had posted. Also...sometimes different med books will shortened and only print what is the usual info used/needed. Sometimes you can only find out the full info on a med by reading the drug inserts from the boxes. Everytime I see a new med in a box...I always try and get a copy of the it. There have been many times I have had to call a Pharmacist...and have him pull the insert and read it to me...because we couldn't find the med in even the newest PDR!

You know...so many times...I look at what I wrote, and have to edit numerous times...even after I try and read it over before I press the "submit" button. I'm always amazed at what I thought I wrote, and what is actually posted. It's difficult to relay your thoughts to print, at least for me it is.

You're are so very right about...Our minds seeing what they are expecting to see.

RN-PA..

I'm so very sorry to hear about your experience. For some reason... tears started coming to my eyes as you related the pt. having to endure the q1hr Accucks. I know this must have been a test of endurance for you also. I guess I'm still also thinking what could have happened with my own error.

I hope and pray that what we have related here will help another new or old nurse to not repeat our mistakes.

Fran-RN...I would have totally freaked also.but good save on that

one! WheeW!!

I'm going to go outside and get some fresh air!

[RN-PA, RN]

Brownms, I was terribly upset about my med error but more upset by the q1h Accuchecks. (We need an emoticon with tears flying out of its little blue face...)

Not that I'd want this to happen to ANY patient, but this Insulin error happened to a patient who I had grown to love during her previous admission and who, along with her family, also loved me. She told me I looked like Julie Andrews (you'd have to squint to see any resemblance, IMHO) and so when I'd give her meds, I'd sing "Just a spoonful of sugar..." and sing snippets of other songs from Mary Poppins or Sound of Music. When she saw me for the first time during that post-op admission, she yelled, "JULIEEEE!" and reached up from her bed to hug and kiss me. I can hardly convey how really badly I felt that night after my error... *sigh*

[Brownms46]

Dear (((((RN-PA)))),

I'm not sure why...but I felt the sadness all the way here in WA! Yes we do need that emoticon!!! What a joy it must be for your pts. to have you as their nurse! I like nurses who do the out of ordinary for their pts.

And Renee...lady...we will have to meet when I get to TX...which should be next month now.

You know I try to remember to pray everytime I go to work. Before I open my door...I sit in the parking lot...and say something like this.

Lord ...please give me a servant's heart...let me keep my mouth closed, and my heart , mind, and ears open. Let me find no fault in those I work with...and let them find no fault in me. Let me see you in each bed...and let them see you in me. Let those who I care for benefit from my care, and let me do no harm...Amen

[RN-PA, RN]

Thank you for the hug and kind words, Brownie :kiss. I love this BB and wish it'd been around when I was in nursing school and the years following, but am thankful for it now and for all who contribute, teach, and sometimes confess here. The great stories and humor are indeed healing and so helpful.

Your prayer before work is similar to mine. (Don't worry, anybody-- I have NO intention of turning this into a religious discussion thread!) I pray to love my patients and co-workers, to please God and serve Him through my thoughts, words, and actions, and to be competent and safe. When the bad things happen, I wonder why God didn't protect my patient or alert me somehow, but I now have figured that if I HADN'T prayed, how much worse might the situation have been.

[Brownms46]

Dear RN-PA,

You absolutely, totally 100% correct , and I agree with you everything you have said... Have a wonderful weekend,..:)

[mustangsheba]

All good posts here. I've been around 20 years or so, and as someone just said, there are days (or nights!) that are just going to make you feel s***ty! My reality check is two questions: 1. "Did anyone die?", and, 2. "Should they have?" If I can answer no to those two, I force myself to move on. I was lucky when I first started. Several of us would meet at a little pub and decompress. I think this is especially important the your first year of nursing. I will encourage you to not stand around more than a couple of minutes trying to figure out what an order means. Call the one who wrote it and get clarification. Not only do docs have bad hand writing, but they get tired and distracted too.

[live4today, RN]

That's a deal, Brownms46! We're on base, so not hard to find that's for sure! Send me a "pm" here, and I'll let you know where to find us.

[Brownms46]

So right you are mustangsheba....but sometimes hard to get pass it when you're in the moment.

Great Renee....been a long time since I was there....but I have to come through there....so it would be a nice break in the drive to the coast. Thanks for the offer!

[nursevilla]

that reminds me of the time i called a code on someone who had died on my watch, and i got in trouble for "panicking". i thought i was supposed to push the button if there is no pulse or respirations. and me a CPR instructor for 10 years at that point (but new to nursing). always remember you are first human, then a nurse. good luck.

[rncountry]

shavsha----:kiss welcome to the human side of it all.

Matt, Lake Wobegon, say hello to all the Norweign farmer guys would you? You must be an ok guy.

[teeituptom, BSN, RN]

Howdy Yall

From deep in the heart of texas,

Dont knock yourself out because of a med error. Weve all done them at least once. No matter how good a nurse youare. Its a learning and growing pain we all go through. And if you ever work with a nurse who says shes never made an error then she is either lying through her teeth or she doesnt work with patients.

Keep it in the short grass

Teeituptom