major error in NICU

[ana97abby03]

I am totally down in the dumps. I have been an RN in pediatrics for almost nine years now. I have been working in NICU since last April. I made my first error the other night and I am on the verge of getting out of nursing or a major depression. maybe both. I reset an IV for a coworker (who has 25 years NICU experience). I was only going to put 50 ml in the buretrol b/c that is what I normally do for safety. I had the pump correctly set at that point. She asked me to put a hundred and was standing next to me. I accidently put 100 as the rate insead of 13.7. This was D17 TPN. The baby had about a 45 ml bolus before she caught it. He was very shaky and the glucose went sky high and then bottomed out but finally leveled out. He was already having glucose instability and very sick with meningitis. The NNP responded and tried to comfort me. I did the incident report and took full responsibility even though other nurse was standing there with me since I set the pump. The only blessing is that this was a term baby rather than a 600 gram preterm. In that case the baby might have died. I can't stop crying. I haven't heard anything from my boss yet, but I am sure the story is all over the unit. I was caring for the three intensive babies and so was my coworker. Staffing is not safe when our census is up, however I still messed up. I am wondering how to get over this or should I just find another job.

[CaseManager1947]

In our hospital, all TPN infusions require two nurse sign off, just like narcs, Insulin verification. Most errors like the one you describe do have a "root cause". That is why a root cause analysis is often done by management in sentinal events or serious patient errors. This is an opportunity to learn from an error. Maybe your institution should investigate a policy change such as our hospital did for this high risk, problem prone intervention,

[Aneroo, LPN]

Regarding the IV pumps, I actually thought a few times that they are unsafe. I have worked with much better pumps with guardrails and separate buttons for rate and volume (the one I was using you have to scroll down. We only use the plum pump for the TPN. We use syringe pumps for everything else and they are also much safer. For small babies the syringe pump would be fine for TPN (we actually do that for for umbilical lines). I plan to mention all this to the risk assessment people. Not to defend myself, but hopefully to prevent it from happening to someone else.

This is why we fill out incident reports. I remember writing myself up over something coworkers thought was stupid, but it all goes to improve outcomes. Maybe someone else on another floor had something similar happen and risk mgt. can see that and suggest appropriate changes.

(hugs) to you!