The Face of a Medical Error...

Ruby Vee, BSN · Jun 27, 2014

It's been a dozen or so years, but every now and again I see a face in my dreams. It isn't the face of my patient -- I doubt I would ever recognize her again. It's the face of her husband, and how it crumpled as the physician told him about the error that claimed her life. I didn't err alone -- I was one in a long chain of nurses and providers who had passed this woman from the ER to the Med/Surg floor and finally to the unit without passing on the one piece of information that I never could have guessed and that would have explained her symptoms immediately and clearly. But I didn't get the information, and therefore I didn't act on it and because I didn't, a young life was lost.

There was an investigation, of course. I don't know about how anyone else was investigated, or if they were. In my case, it was pulling me away from my patient in the middle of a shift, closed doors and a psuedo-sympathetic suit grilling me I what I had known and when I knew it and what I did about it. Over and over. I'm sure there were closed door meetings among management as well. "SHould we fire her? Will that make us look more guilty or less guilty? Is she likely to raise a stink if we fire her?" If we make an example of Ruby, is she going to talk about all the OTHER people in the chain who could have prevented this by passing on that one relevant piece of information?"

In the end, I kept working. Some of my co-workers talked about me behind my back and some of them were wonderfully supportive and compassionate. All of those voices died down, and the incident is lost in our communal memory. If anyone brings it up, they don't do so in front of me.

I've forgotten a lot more slowly. I no longer remember the name of the patient, or HER face, but I'll never forget her husband's. And some days, he invades my dreams and I grieve once again for the harm I was a part of doing him.

Guests · Jun 27, 2014

Wow, Ruby... That's powerful.

I'm fortunate that my patient was fortunate enough to not have suffered permanent damage so far as I know.

This was terribly difficult even without death... I can only imagine how much more difficult it would be to cope with knowing that I'd had a role in someone's demise.

Esme12, ASN, BSN, RN · Jun 27, 2014

It's been a dozen or so years, but every now and again I see a face in my dreams. It isn't the face of my patient -- I doubt I would ever recognize her again. It's the face of her husband, and how it crumpled as the physician told him about the error that claimed her life. I didn't err alone -- I was one in a long chain of nurses and providers who had passed this woman from the ER to the Med/Surg floor and finally to the unit without passing on the one piece of information that I never could have guessed and that would have explained her symptoms immediately and clearly. But I didn't get the information, and therefore I didn't act on it and because I didn't, a young life was lost.
There was an investigation, of course. I don't know about how anyone else was investigated, or if they were. In my case, it was pulling me away from my patient in the middle of a shift, closed doors and a psuedo-sympathetic suit grilling me I what I had known and when I knew it and what I did about it. Over and over. I'm sure there were closed door meetings among management as well. "SHould we fire her? Will that make us look more guilty or less guilty? Is she likely to raise a stink if we fire her?" If we make an example of Ruby, is she going to talk about all the OTHER people in the chain who could have prevented this by passing on that one relevant piece of information?"
In the end, I kept working. Some of my co-workers talked about me behind my back and some of them were wonderfully supportive and compassionate. All of those voices died down, and the incident is lost in our communal memory. If anyone brings it up, they don't do so in front of me.
I've forgotten a lot more slowly. I no longer remember the name of the patient, or HER face, but I'll never forget her husband's. And some days, he invades my dreams and I grieve once again for the harm I was a part of doing him.

Wow.....((HUGS))

Anyone in medicine long enough has been apart of something HUGE. Sometimes it takes a patient's life sometimes it doesn't.

We are.... after all.... human.

Susie2310 · Jun 30, 2014

I have learned that when a patient or their family member questions a medication/dose or expresses reluctance to receive said medication/dose, it is extremely important to pay attention. Don't assume anything about the patient because of their diagnosis/diagnoses. Check the doctor's order. Follow the five/six/seven rights and always understand why the medication/dose is ordered and why it is indicated now based on patient assessment/history. Question any order that appears incorrect/unsafe, or that the patient is questioning/is reluctant to receive. That medication or dose may have been discontinued by the MD or may have been a one time only dose, and this may not appear accurately on the MAR. Don't assume that other people have done everything correctly up to the point that you are the person in the chain charged with administering the medication.

**NickiLaughs, ADN, BSN, RN** · Aug 16, 2014

It's so hard to slow down in the ED environment. I've made my mistakes too. I caught a dangerous error once, patted myself on the back and then the same year, not paying attention to the med in the Pyxis (well it was supposed to be Levophed, but guess the pharmacist got busy). I got through my double check after pulling a med with another nurse, she glanced and confirmed. Then after mixing the drip, I glanced one last time...holy crap, it was a neuromuscular blockade!!! That resulted in me promptly throwing up and a sweaty crying mess in a corner. I never threw a med in the pharmaceutical waste bin so fast!

I ca only imagine what this would have done to my hypotensive non intubated patient , likely Immediate death.

I'm grateful everyday for that quadruple check I did, mad at myself for not catching it sooner, and also grateful for the nursing student who was by my side who learned hands on how med errors happen. I'm hopefully a better nurse for and OP, I know you are as well. :)

OCNRN63, RN · Aug 16, 2014

It's so hard to slow down in the ED environment. I've made my mistakes too. I caught a dangerous error once, patted myself on the back and then the same year, not paying attention to the med in the Pyxis (well it was supposed to be Levophed, but guess the pharmacist got busy). I got through my double check after pulling a med with another nurse, she glanced and confirmed. Then after mixing the drip, I glanced one last time...holy crap, it was a neuromuscular blockade!!! That resulted in me promptly throwing up and a sweaty crying mess in a corner. I never threw a med in the pharmaceutical waste bin so fast!
I ca only imagine what this would have done to my hypotensive non intubated patient , likely Immediate death.
I'm grateful everyday for that quadruple check I did, mad at myself for not catching it sooner, and also grateful for the nursing student who was by my side who learned hands on how med errors happen. I'm hopefully a better nurse for and OP, I know you are as well. :)

What I want to know, is did the nursing student see you boot? That would have been one awesome post-conference if she did.

I'm glad you did that quadruple check. Your story was a sobering reminder of just how closely we must pay attention to what we're doing, even when we think we're already paying attention. ((HUGS))

allnurses Guide · Aug 17, 2014

A good article. What it doesn't say is that nurse staffing is key to preventing errors and complications.

Joel Hay: What's wrong with American hospitals?
... How long would the airline industry survive if two large commercial jets crashed every day in the U.S.? How long would the auto industry survive if driving were twenty times more dangerous than it actually is and getting riskier every year?
Despite 15 years of concerted effort to improve hospital safety, medical errors and complications have actually gotten worse, affecting one in three hospitalized patients.
It would be one thing if hospitals were inexpensive, but we spend nearly a trillion dollars on hospital care each year; one-third of total health care spending. According to a recent Journal of the American Medical Association study, the average hospital netted a median profit of $18,900 per surgery, but when the surgery went badly the hospital's average profit rose to $49,400.
Complications doubled profits if the patient was covered by Medicare and tripled profits if the patient had private insurance. "If a patient has colon cancer surgery, Medicare pays a certain fee, but if the patient gets a post-operative infection that leads to pneumonia and has to be put on a ventilator for several days, the payment for ventilator care is higher and more profitable than the payment for the original surgery," said Dr. Rosenberg, a study author...
http://www.ocregister.com/articles/hospital-600886-care-year.html

allnurses Guide · Aug 17, 2014

Nurses need better working conditions to reduce medical errors

The nation's 2.2 million registered nurses, 700,000 licensed practical and vocational nurses, and 2.3 million nursing assistants are the front line in caring for patients and protecting them against errors, the report said.

It cited a study in two hospitals that found nurses intercepted 86 percent of medication errors before they reached patients.

http://sci.rutgers.edu/forum/showthread.php?11780-Nurses-need-better-working-conditions-to-reduce-medical-errors

allnurses Guide · Aug 17, 2014

Interruptions Linked to Medication Errors by Nurses

http://www.medscape.com/viewarticle/720803

Kissy1818 · Jun 1, 2015

This is an old post but I have found what you wrote hits home and has helped me a lot, we can all make errors and be involved in errors and it's the worst feeling ever. I just wish I knew how to forgive myself.