Made a bad mistake today - lucky escape (long)

[bethem]

I am on prac in our biggest local hospital's ICU. I absolutely love it there, and I am even considering changing my new grad preferences to Critical Care instead of my first love, paediatrics.

Today I made a really stupid and potentially deadly mistake. My supervising nurse asked me to draw up and administer the pantoprazole and benzylpenicillin for my septic patient with cardiogenic shock. Easy, done it a hundred times before. I gave the pantoprazole through the free lumen on the central line, then turned to the trolley to get my flush. I turned back to the patient with the flush and the penicillin and started to give the flush - into the arterial line. The one with the bright orange sticker warning me that it was the art line.

The alarm went off because the transducer in the art line was not getting a reading, and I merrily explained to the man's daughter that it was nothing to worry about, the alarm goes off when the transducer can't get a reading on the blood pressure. Thankfully the RN realised what I was doing and stopped me by saying, "Yep, that's great, now just give the other line a flush as well," so as not to worry the daughter. My heart just stopped and I tried so hard not to react in front of the daughter. I just could not believe that I had almost put penicillin in an arterial line. I was mortified, but I had to wait till the daughter left to say anything to the RN.

She was fabulous, and said, "Look, it could have been bad but it wasn't. If you had to make this mistake, this is the best possible way to make it cause it's just the same as flushing his art line with the hep saline, except you've done it without the heparin. You know you'll never do it again now, because this will stick in your mind forever. Don't beat yourself up about it."

I'm trying not to, but my stars, that could have been so bad. I am in my last year, in fact I will graduate in three months, and I made a mistake like that.

I just wanted to get this off my chest, but if anyone has any "I made this mistake when I was a student/new grad" it would help me feel better!

[kaitsmama]

I just wanted to get this off my chest, but if anyone has any "I made this mistake when I was a student/new grad" it would help me feel better!

I am sorry I don't have any, "I have made this mistake..." stories, but I was following a long-time nurse that made a major med error. It was only my first clinical rotation and I was still so nervous and green that I know it will stick with me FOREVER! The nurse had several red flags prior to administering the drugs, but she continued due to being behind schedule and everything being so routine. She administered the patient another patient's drugs

It was a bad situation that turned out ok, but it was scary for everyone involved!

I agree with the nurse that was with you...could not have been a better way for that situation to have happened. You learned a big lesson before being out there on your own! Learn from the situation and move forward with confidence that you will be more cautious in the future.

Laura

[Tweety, BSN, RN]

You're nurse was right. You learned a valuable less, that you will never repeat again. Don't beat yourself. up.

[bethem]

Thanks to both of you. I feel a bit better about it today after some sleep and some distance.

I appreciate your support.