i haven't been a nurse long, but i have been involved in a very significant medical error (please understand that this is not me saying you made a mistake...i have no way of knowing that from where i sit). during my preceptorship in the last term of nursing school
, a baby i was working with had to have his lipids and tpn switched out d/t expiration dates (they were changed every 24 hours). i was being instructed in how to change lines for babies that have picc lines. you have to be quick and get it done because these lines can clot off very quickly.
unfortunately, a few things occurred during this time that caused the lines to become switched in their respective pump channels. the tpn and lipids were now running at completely the wrong rates. this was not discovered for almost 24 hours, and then the only reason it was caught was because a triglyceride test was miraculously drawn that day and came back very critically high.
now technically speaking i was working directly under the license of the nurse i was working with, and she didn't check my work entirely. however, i was still the one who put it together wrong. devastating, to say the least. i will say one thing though...i effected a hospital-wide process change. risk management and quality improvement got involved, did interviews and decided that a couple of policies were inadequate or missing.
moral of this completely different story is that even if you are by some chance in the wrong, you have stated that you followed your policy and procedure. you were only doing what you knew how to do based on what the organization told you was right. one of the most unfortunate things about healthcare (that i am not even sure how to improve) is that mistakes sometimes have to be made before improvements can be made. i know this is a small consolation when you are sitting there tearing your hair out trying to understand how you could have done it differently...but know that you have probably effected a change that will help more people than you will ever be able to touch.