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Joined Sep 10, '08. Posts: 24 (25% Liked) Likes: 21

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  • Jan 18

    A former colleague of mine, a lovely woman I'll call Lauren, made an enormous and fatal medication error on her first night shift off of orientation. She gave 5 mg. of digoxin IV push-not 0.5 mg. She drew up and injected 10 vials of digoxin. She recognized her mistake almost immediately afterward, but it was too late for her patient. After a prolonged code, he died. Lauren learned a hard lesson, and she learned it in public, but she handled it in the best way I've ever seen anyone handle such a disaster. It's been 20 years, and Lauren went on to become a great nurse, a wonderful preceptor and now a nurse practitioner. How did she survive such a career-ending and license-shredding catastrophe? I'm going to tell you.

    Everyone makes mistakes, absolutely everyone. There is no such thing as a perfect person, and since all nursing students, CNAs, LPNSs, RNs, and providers are human, there are no perfect nursing students, CNAs, nurses or providers. Nursing school doesn't really teach you to be a nurse; it just gives you a glimpse into the world of nursing. The NCLEX merely gives you a license to learn. If you're smart, you will learn something new every day of your career, and if you're very very smart, you'll learn how to handle those moments when you've been very, very stupid.

    Anyone who tells you they have never made a mistake is either lying or too ignorant or stupid to realize they've made one. Understand from the very first moment that you don a set of scrubs and a name badge that says "Student", "CNA" or "Nurse", you WILL make a mistake. Mistakes are inevitable; they're part of life and they're part of nursing. What matters isn't that you're perfect; what matters is what you do after you've made that mistake.

    I've known a few people who were so convinced of their own perfection that they couldn't recognize their own imperfections. If they did it or thought it, it must be correct. If you are not open to the possibility (inevitability) that you might make a mistake, you are not likely to realize when you've made one. If that thought doesn't scare the pants off of you, it should. If you are unable to recognize having made a mistake, it will be impossible for you (or anyone else) to fix it. The very first thing to do when you've made a mistake is to recognize it. The second thing to do is admit it.

    Admitting a mistake is scary and difficult. No one wants to appear stupid, no one welcomes the idea that others might be judging them. But our job is too important not to admit our mistakes, and the stakes-for other people-are far too high.

    It's amazing how resilient patients can be, and how few medical mistakes actually kill patients or even cause them permanent injury. Some do-we all know that. Anyone who has heard of Peter Pronovost knows that safety is a huge concern in hospitals today. But if you recognize your mistake, admit it, and immediately set about to minimize or mitigate the damage, most mistakes are merely a bump in the road rather than a career ending or life changing catastrophe.

    Years ago, I worked in a SICU with a nurse I'll call Janet. Janet was beautiful, funny, smart and generous. I met her my first week on the job, and we became friends immediately. We went hiking and biking and dining and dancing, and we always had a great time together. Janet was a lot of fun. But she also lacked integrity. One day I was in her room with her at work, helping her to turn her fresh-from-the-OR patient. As we turned him, we heard the monitor start to alarm, and we looked up in horror to see his heart rate slowing down, passing 30 on the way south. The surgery fellow was just outside the room and responded instantly to my involuntary utterance of an expletive that means fecal material.

    There were many interventions, but the one that sticks forever in my mind was the order to give "Point one milligram of epinephrine." Janet grabbed up the emergency bristojet of epi at the bedside and pushed the entire thing-one milligram. Suddenly we had the opposite problem. The patient's heart rate picked up-slowly at first-but rapidly gathering steam. From no blood pressure and a flat art line, we suddenly had a pressure of 250 systolic and climbing, and a heart rate in the 200s. "How much epi did you give?" shouted the fellow in alarm.

    "What you said," was Janet's reply as she slid the empty syringe out of view.

    "How much was that?"

    "What you said!"

    "How much was ordered?"

    "I gave what you said," she insisted, despite the clear evidence to the contrary. The chest tubes were full of blood and the pleurevac overflowing. We whisked the patient back to the OR, leaving a bright red trail of blood in his wake. Janet never budged from her story-never. Her mistake didn't kill her patient because the quick thinking and quicker actions of that surgery fellow, but I never trusted her again, and it was pretty much the death of our friendship. The fellow-who is now head of surgery at the hospital where Janet still works-has never trusted her again either. He's put an end to more than one promotional opportunity she's set her sights on.

    As soon as you recognize that you've made a mistake, tell the appropriate person. It's not enough that you recognize and admit your mistake; the next thing is to do everything you possibly can to prevent, minimize or mitigate the damage. If you've made a medication error, tell the provider. There may be, and usually is something that can be done. Narcan reverses a narcotic overdose, protamine reverses a heparin overdose and if you've given too much insulin, you can give sugar. But you'll need a provider's input and a provider's order.

    Once you've done what you can to help the patient, take a moment to think through the process that led to your error. Were you rushed? Distracted? Overtired from overtime? Didn't understand the order? Whatever the cause, you need an understanding of how and why you made your error and what you're going to do differently next time to prevent it from happening again.

    You're going to have to tell your manager. There are right ways and wrong ways to tell your manager, but whatever you do, make sure YOU tell her before she finds out from someone else. This is even more important if it was a big mistake or if the consequences to the patient were dire. Call her at home, email her-whatever it takes. There's nothing worse from a manager's perspective than to be blindsided by someone who comes to confront her about a mistake made by a member of her staff. Even if you don't have time to write down the particulars, make sure your manager knows you made the mistake before someone else tells her.

    A colleague of mine once shocked a patient in normal sinus rhythm because he mistook artifact for V tach. He was new to ICU, and some artifact does look a lot like V tach or V fib. Dan "defibrillated" his patient in full view of an entire team of doctors and a couple of nurses, most of whom were yelling at him to stop.

    "Oops," he said afterward, with a laugh. "I shouldn't have done that." No one else was amused. Our boss wasn't terribly amused either, when she heard the story and Dan is long gone from our unit.

    You want to make it perfectly clear to your boss that you realize you've made a mistake, that you understand that the consequences were (or could have been) humungous, and that you're profoundly upset with yourself, sorry for your error and worried about the patient. You also want her to know that you've thought through the process that led to your error and that you have a plan for making sure it never happens again. I can tell you from personal experience that you can survive a sentinel error with your job and your license intact-if you recognize your error, admit it, tell the people who need to know, set about to mitigate the damage and tell your manager in the right way. Lauren not only survived but went on to thrive in her nursing career-not because she never made a mistake, but because she showed enormous integrity in what she did after she made one.

    Last, but far from least, forgive yourself and move on. That's often the most difficult part of the entire process. But NOT moving on condemns you to relive your mistake over and over again, undermining your confidence, destroying your sleep and making it far more likely you'll make more mistakes. That's a vicious cycle. Forgiving yourself isn't easy-I'm still working on it-but it is necessary. Writing helps me to move on, others may benefit from talking to a therapist or counselor. If that's what it takes, do it. Some workplaces even offer counseling as a benefit to employees who have been a part of a sentinel event.


    You WILL make a mistake-just make sure you deal with it with honesty and integrity.

  • Jan 2 '14

    well, didn't Hillary Clinton say when Bill had surgery that all the nurses do is give meds and are overpaid? She was also the same one who pushed Obama into a healthcare plan which cuts reimbursements so low that the "overpaid med-pushers" are eliminated by budget constraints. You get what you pay for. Of course, they will always be treated as VIP's so will never understand our plight.

  • Dec 5 '13

    Please stop antagonizing and being rude to patients and families and then look incredulous when all the quiet rooms fill up you're giving 3 IMs and patients are signing 72 hour notices when you work. I don't know why you need feel "powerful" with the pts. They are PSYCH pts. You have all the power in the world already. Oh, and everyone who works weekends with you as charge totally dreads it.

  • Dec 5 '13

    First off, not only are you failing at the look you are wanting to achieve, but it is completely inappropriate for work. Don't come on a busy med-surg floor in open toed platforms. Don't wear velour sweatpants that still manage to be see-through, with awful looking underwear clearly visible. DO NOT wear skintight V-neck t-shirts to show off your new pair of silicone fun bags. These confused LOM do not need the stimulation, and the LOL's look like they just might have a fainting spell from your revealing look. And for God's sake...your hair looks like straw. Either quit bleaching the crap out of it every couple of weeks, or invest in a really good deep hydrating treatment. It looks like it would crinkle if I grabbed a handful, its just plain damaged. YOU ARE A NURSE, a professional, try to look like one.
    Second, the shift starts at 8am. Not 8:02, not 8:05, and certainly not later than that. Once in a while would be annoying, but if that's all it was, and you at least had the decency to call to let us know you would be late, it might pass. But EVERY day? EVERY ONE?! You have the gall to stroll in with your fake smile, your cup of coffee from the atrium right across the hall from our department that is the reason you are late every day, and take time to chat before taking report? REALLY?!
    And third, do not even dare to give me attitude when you finally make your way to take report from me and I hand you the charts, tell you nothing important happened, and walk off. A) You and I both know that you have had these patients every day this week, and so have I. B) Since we have both had these patients all week, I have had to deal with you coming in late every day as well, and I am now tired of it. C) I was ready to give you a nice, detailed report 20 minutes ago. It is now 20 minutes PAST the end of my shift, it was the night from hell, and all I want to do is go home and sleep. You are an adult, anything that was important was charted, you can read it from the chart. kthanxbye

    Ugh, all to the same nurse...

  • Aug 29 '12

    I have spent the last two days interviewing candidates for an open RN position on my floor. Last week I went through the 14 resumes HR sent over to pick out the ones I wanted to interview. Eliminated eight of these for various reasons ( poor grammar and spelling, history of job hopping, inappropriate email address), and scheduled six interviews. I did the last interview this afternoon, and still have not found a suitable candidate. I know there are plenty of resources online that give job search tips, so please, put a little effort into writing an appropriate resume, and learning how to interview. I don't care if you are old, young, fat, thin, new GN or crusty old bat, gorgeous or if you wear a paper bag over your head. Please present yourself in a professional manner when interviewing. You don't need to wear a business suit, but don't come in jeans or shorts. Don't come with overdone hair and make up and tons of bling. Learn to communicate in a professional manner as well. You are a college graduate, you should at least have an understanding of basic grammar and know how to express yourself. Express a sincere desire to work on my unit. Don't tell me that you really don't want to work on a telemetry unit, that you just want to get into the hospital so that you can transfer into ICU as soon as there is an opening. Don't be cocky or dismissive of CNAs and other ancillary personnel when I introduce you to the staff for the peer interview.

    I have read numerous posts from nurses who cannot find jobs in the present economy, and I feel for them. But it can be just as frustrating for a manager looking for staff who are professional, caring, and committed to their profession. I feel like the last two days have been a complete waste of my time. Please, if you are lucky enough to get an interview, make sure you are presenting yourself as a professional. If you cannot make the effort to do so, don't waste your time or mine by even scheduling the interview.

  • Aug 24 '12

    Here is more gems. I made a post on this when it happened. I once provided terrible service by not bringing chairs for VISITORS quickly enough. One of them was standing in the hall way saying, " WE ASKED FOR CHAIRS, WHERE ARE THEY?" only a few minutes went by. MEANWHILE when I left the room initially to get the chairs, I HEARD FROM THE HALLWAY, THAT one of my other patient's needed a trach suctioned STAT. that is the priority NOT THE CHAIRS FOR visitors. Yet some uneducated visitor is at liberty to whine about "poor nursing" when she and her entorouge do not get their chairs within 5 minutes. Those are the service scenarios that nurses can't stand. Or pts who complain about getting awoken for IV abx. I can go on and on. Sometimes I think I should pack my stuff, go back to a big city and work in a bar, restaurant, etc where I can put my service skills to good use and get paid tips. lol

  • Aug 24 '12

    The economic climate in this country still remains somewhat sluggish several years after the official end of the Great Recession. In addition, dwindling reimbursement rates from Medicare and private insurance companies have placed an undeniable pinch on the financial bottom line of healthcare facilities across the United States.

    Managerial and administrative personnel at hospitals, nursing homes, and other types of entities that provide patient care are under pressure to find ways to slash expenses at every corner to adhere to fiscal budgets. Some questionable methods to keep costs under control may include short staffing, skimping on supplies, and implicitly pressuring hourly workers to get 'off the clock' by a certain time. It is common for many facilities to have written policies explicitly stating that staff members are to clock in no earlier than seven minutes prior to the start of their shifts, and must clock out no later than seven minutes after the scheduled end of each shift.

    The practice of working off the clock is all too common in the healthcare industry. According to Osman (2011), the US Department of Labor ("DOL") has pledged to investigate compensation practices throughout the health care industry after finding that many hospitals and nursing homes were not properly paying their health care workers in violation of the Fair Labor Standards Act ("FLSA"). In addition, it is difficult to know how many nurses and other healthcare workers work while off the clock because employees are generally reluctant to discuss this issue out in the open. In other words, the full scope of the problem remains unknown.

    Non-exempt employees who receive hourly pay should do everything in their power to refrain from working off the clock under any circumstances because negative consequences might arise. First of all, working off the clock is illegal. Secondly, most companies have policies that strictly forbid the practice of working off the clock. Third, most nursing liability insurance policies do not cover nurses for any work performed while not clocked in, which would leave the nurse vulnerable in the event of future litigation.

    Fourth, healthcare facilities may file HIPAA violations against employees who are working while not on the the clock. For example, many nurses review patient charts prior to punching in for their shifts, but this activity could get them into trouble if someone decides to pursue the issue any further. Also, numerous nurses remain at their workplaces after their shifts have ended to chart while off the clock, which could get them into trouble. Furthermore, any injuries sustained while the healthcare worker was not on the clock may not be covered under worker's compensation policies.

    Finally, working while off the clock allows short staffing to continue because companies save money through unpaid work. It leaves administrative staff at healthcare facilities under the impression that a massive workload can actually be completed during the course of an 8 or 12-hour shift. After all, everyone is clocking out on time if they work off the clock. Right? Sure!

    Nurses and other healthcare workers who routinely work off the clock are placing themselves in vulnerable positions. If every single worker remained on the clock to complete unfinished work, this might force corporations to confront staffing issues, heavy workloads, and other issues that hinder people from leaving on time. It is time to be paid for all of the services rendered. Do not work if you are not clocked in!

  • Aug 9 '12

    To promote someone to manage a staff who he does not have respect for would have been catastrophic.

  • Jul 27 '12

    I make my worst mistakes, and am brought lowest, when I start feeling superior and holier than thou. I don't know if it's karma, cosmic justice or what. Just when I've dogged my fellow nurse about a stupid mistake they made, I make one bigger.
    I've learned to address the mistake without judgement in an effort to not tempt fate. The fact that it usually works may simply be chance. Or not.
    I definitely don't call for someone's head, because mine might be next.

  • Apr 22 '12

    I miss the bell that we used to ring in our oncology ward when visiting hours were over.
    I remember how proud I was to be issued with my six white dresses (that the hospital would wash for you each week).
    I miss the night duty care packs we were issued with the apple, sandwiches, juice and yoghurt.
    I miss my first boss (most incredible woman, and superb nurse) who used to smoke cigars in her office and take the patients in there on the sly, who called me braindead and useless for at least six months and made me cry, but made me a better nurse and taught me everything I never learned at university.
    I miss being called "sister" and my badge starting with SR .........
    I miss working when there was no such thing as the internet, facebook or mobile phones.
    I miss the faith and trust that patients inherently had in those caring for them.
    I miss the doctors who wore bow-ties.
    I miss the old autoclave, I can't believe I was nursing when we still sterilised our own equipment!
    I miss the funny side of nursing and the practical jokes we used to play on each other and our patients because we had time!
    I hate to admit it but, I miss the old school polite hierarchical "rules" of being a junior nurse and how things changed as you grew and became more experienced, I loved becoming more respected as I "grew up" and got promoted based on clinical skill development and leadership encouragement that was inherent in the system 15 years ago rather than the system that rewards ego driven entitlement.
    I miss having empty beds.
    I remember passing out while on my clinical pracs as a student because etiquette demanded that we stand quietly, in non-air conditioned wards (forever) while the RNs did group handover, and having my facilitator catch me, throw me into a chair and give me a juice (no trip to the ER).
    I remember drawing up our own chemotherapy.
    I remember working when the word "bully" only applied to school children.
    I miss working with nurses who devoted 40 years of their lives to looking after people.
    I miss working with doctors who devoted 40 years of their lives to looking after people.
    Oh, I know, I am a sentimental fool.

  • Apr 12 '12

    mindlor, I'm not sure why you are fighting so hard to assert that the RN who left the patient in need of a bedpan was correct. The overwhelming consensus here would disagree, since it's the patient's needs that come first, not the need of the RN to stand on ceremony and stick to a hierarchy. The RN who spends more time looking for someone to do the job that would take her less time to complete isn't using good time management. If there was an aide who could never be found, and everyone had to do her job for her, then yes, that's a different issue. But taking just a few minutes to place someone on a bedpan to relieve the patient's discomfort is using very basic nursing judgment. The only person punished in making the patient wait is the patient.

    Those of us who have worked busy floors with upwards of ten patients (med-surg, tele, whatever) already know how to delegate or we couldn't survive a shift. When the staffing is good/appropriate, there's typically enough time for everyone to do everything they need and even get breaks. When staffing is bad, though, it's good to know that you can count on those same CNAs you seem to think of as 'underlings' to pitch in and help as much as humanly possible. They can be your best friend if you're in a crunch, and they know THEY can count on you for assistance when it doesn't kill you either.

    Perhaps once you've worked as an RN (and I do mean for more than a single day of preceptorship), worked for say a few months, you might come to understand what everyone here has been trying to get across. I say this as someone who, I'm a bit ashamed to admit, sounded quite a bit like you when I first became an RN. Ashamed, in that I eventually realized that School Book Reality and Real Life Reality really were very different at times, and a little humility goes a long way. Just maybe something to consider.

  • Apr 12 '12

    Quote from mindlor
    any of ya'll have 8 pts on a busy med surge floor?
    ^ No, but I have had 7 tele patients on a busy cardiac surgical floor. I can tell you as one who has been a tech and a nurse, it is 10 times faster to put the patient on the bedpan yourself than to run around and find a tech to do it. If I am really busy then I will put the patient on the pan, give them a call bell, and give them some privacy. AFTER I leave the room I will ask the nearest tech to watch out for the call bell because I need to do XYZ. And I will ask kindly, with respect. Please oh please do not become the kind of nurse that expends more time/energy to find someone else to do work that you are perfectly qualified to do, than it would to just do it yourself.

    Let me reiterate, in most situations it will SAVE you time to do this kind of work yourself than to search for someone else to do it for you. Not to mention it will improve those all-important patient satisfaction scores.

  • Apr 12 '12

    Quote from karen2012
    i have hearing issues and yes i was born in the states. i hope you don't mind someone like me being member of this forum. as for your information i am also half black is there other concerns?
    speaking only for myself, i don't give a rip if you're half black or if you're red and white striped or simply polka dotted. not an issue. and for the purposes of this forum and this thread, your "hearing issues" are not pertinent, either. what is pertinent is that you have failed the nclex three times, and you thought it was unfair because you "knew in your heart" that you had passed. you're going to take it a fourth time, but as late as a few posts upthread, you had no plans to change the way you study or what you study. you dismiss out of hand anyone who disagrees with you or who says anything you don't want to hear -- however well-intentioned such comments may have been.

    if you manage to pass the nclex and then manage to land a job, are you also going to dismiss out of hand anything your preceptor says to correct you? because you're not indicating here on this thread an ability to process information that disagrees with what you "know in your heart" and learn from it.

  • Apr 12 '12

    Oh I totally believe it. My old hospital, the only place they would look at you twice L&D/postpartum. I've been there since I quit working there and been in back hallways, front hallways, nobody looks at you twice.
    That said, just because it's something one CAN do, doesn't mean that it's a good idea, and definitely doesn't mean that it's a good idea if you're a guest of the facility being allowed to do your clinicals there.
    It really shouldn't have to be said. Don't take your spouse to work with you. Or school. Don't take your kid with you. Don't take your mommy with you. If one of those people MUST go with you, leave them in the lobby. Or the ED waiting room. Or cafeteria.

  • Apr 9 '12

    I've found that patients who actually are a "VIP" in the minds of administration don't have to tell me they're a VIP, as their administration friends will let me know. If you're telling me that you know so-and-so, it's obviously not too well if they haven't come to tell me to be nice yet.


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