I have been working ICU for 8 months straight out of school. Lets not make tjis into a "new nurses should not go into ICU" thred please, that wont help me.I was called last night and told not to come in this morning to the unit. Instead I should goto nursing services and meet with my manager and her manager. Yikes.
1-Last Friday I admittedly made an error (I work ICU). A Patient was admitted from the floor and i wrote an order for ativan 1 mg q 3 hrs, it should have been PRN, i forgot to write PRN. I reported off to the night nurse about the ativan helping with pain/agitation and he realized not to give that much. The patient got several doses 8 hours apart, but the doc flipped when he saw how the order was written
2- Several weeks ago, I had an extremely agitated patient who was also 350lbs. There was an order for haldol 2 mg ivp prn, no time constraint. The nurse who gave me report said she had been moaning all night and nthing could be done, and that she had proabl;y not slept in days and her solution was to close the glass door so she couldnt hear the pt moan. I felt this to be NOT helpful to the pt. I ended up giving some 70 mg of haldol over the 12 hour shift. I looked up the safe dosage and that falls within the safe dose. Some books say 5 mg every half hour, some say 10 mg, then double until you get the desired effect every half hour stopping at 50mg. At no point did the patient have decreased resp[irations or drop her blood pressure. She fell asleep for a few hours but thats it, all in all even that much haldol was not that effective. That was several weeks ago and I guess they were reviewing the MAR and somone flipped. I also asked the other nurses on the unit, including the charge if it were ok that i give that much and noone said anything other then they had not given that much before but it didnt violate the order or the corecct safe doasge. Also They were upset that I didnt question the order for not havinga time constraint, which i will do in the future.
Fallout- Luckily I didnt get fired but now I must verify ALL medications with the charge nurse before I give them. "charge nurse, can i hang some vanc?" crap... and I am not allowed to work overtime because they felt I have worked too much and was too tired. The crazy thing is I am helping THEM out and they cut my overtime completely!!! I am thinking I will find a new job and put my two weeks in ASAP
The OP obviously didnt learn anythign from this experience. As far as trusting the drug books, they are a guide. Personally, I would value an experienced ICU nurses wisdom moreso than a book. That book hasn't pushed the meds it has in it.
And I can understand you being worried about being fired for another med error. But that same med error could end a patients life. That should put things in perspective, but somehow I doubt it will. You were given a gift, yet you are pretty indignant about it.
My advice? Be glad you kept your job and have some humilty while taking advantage of your coworker's experience. And especially being in the ICU, hone your critical thinking and seek the rationale for orders/procedures instead of just blindly following an order and not questioning it (whether internally or actually calling the MD).
I actually tried to respond to this thread yesterday and it was locked. Just from reading your posts it does seem to me as if you dont think there was any major problem with your mistakes, that people in the unit are just out to get you, and you arent going to admit that you were wrong.
Nurses for the most part are busy, stressed, etc and I will tell you first hand that it may not be right but some nurses wont argue with a newer nurse--they will give their opinion but if the nurse just wants to argue and do their own thing then they will let them hang themselves.
You are a new nurse in a hard environment. You are making life or death decisions frequently. To just be a nurse 8 months and to be able to do this shows me you have a lot of potential. You also have to realize 8 months is nothing and for the next several years of your career there will be five times as much as you dont know vs what you do know. Book learning is important--experience is invaluable though.
The Ativan order was obviously wrong. The wrong medication can kill a patient. Ativan 1mg every 3 hours probably was not going to seriously harm the patient BUT if it was an elderly patient and it was IV then I can see some serious harm coming about despite what the normal parameters may be. I have seen floor nurses knock everything out ie breathing by giving Ativan IV to a small elderly person.
I know other nurses think I am obsessive compulsive but I probably check my orders 5 times. I will often take a medication to a patient then in the hallway go back to the med room and double check the bottle to make sure it is the right drug. It really looks silly but medication administration to me is something I am dead serious about. Being a new nurse in a highly stressful environment I encourage you to at least double check your orders.
You also need to realize that you cant always go by--"it didnt cause any harm so it was alright." You have to look at the potential for harm. If something would have happened with that patient you gave Haldol too, I do not know 1 RN that would say on a witness stand--I dont see a problem with giving Haldol 35 times in 1 shift. Another poster touched on this. You are not responsible for doing what a drug book states--you are responsible to act as any other prudent nurse would in your situation.
If we just read orders and did everything written down then we would be unemployed and they could just find someone off the street who can read and take orders. I think you failed to use the nursing process in this situation. If you had to give Haldol 35 times I just cant see how you are evaluating that as being effective. Also we have to use our nursing judgement.
You admit that you should have gotten a time frame and that will be something you will now know forever because of this which is good. Even if it is Tums get a time frame.
I also question the reference material you are using. That link you provided is for an army hospital in Hawaii. Is that your hospital? If not then another hospital's policy isnt going to help you. That information is also 6 years old now. I have always seen the nursing drug handbook used and for Haldol it says a max dose of 100mg a day PO which is probably 60 IV or IM. I am not for sure it that is a full army hospital but in the military nurses do probably quite a bit more than they can do in the private setting.
Whatever resource your hospital provides is the one you should go by. The internet is great and PDA software is too but again wont take responsibility from you if there is a mistake or problem. Again if this is not your facility how do you know those authors were licensed practitioners with credentials?
I really think you need to swallow your pride and give a full fledged effort. We all make mistakes--noone is going to criticize you for that. God forbid but I realize that I may make a harmful mistake tonight not because I am not caring or competent but because I am human.
It is how you handle these mistakes that count--become a better nurse now. You have learned a lot. If you have people that are out to get you it can be stressful but use that for your advantage. You are going to have to stay on your toes. I had a horrible supervisor one time that would try her best to capitalize on any decision she thought was wrong. How did I deal with it? With knowledge. She would say something and I would be like, "really well lets look at the acls guidelines here, I dont see your intervention listed but I do see mine."
I dont want to see you leave critical care--after a few years of experience you can work anywhere. People will give you multiple job offers, you will have so much respect. If your working environment is that bad then perhaps you should quit--I wouldnt be able to work in a critical care environment that wasnt supportive. There are always going to be 1 or 2 people you dont get along with but when it is 5-10+ sometimes you have to look in the mirror. You also have to realize you are getting a lot more from them than they are from you so be appreciative!
Good luck and again we all make mistakes--it is how we learn.
i am willing to bet that some of the attitude you feel coming at you is from the attitude you are putting out there - you made a mistake. own it, learn from it. don't run from the hospital. work even harder to prove that you can make it in that unit and if, after you've proven yourself, you still want to leave, go. but don't leave now, it looks like you're running away from the disciplinary action, which is exactly what you are doing. the haldol rx wasn't a legal rx, and you had a responsibility to clarify it. just because you have a drug book, doesn't mean you get to rx drugs. when you were deciding how often and how much to give the pt., you were essentially rx'ing the med yourself.
you need to take a step back and accept responsibility for your actions and know they were wrong and learn from them. you can survive checkign with the charge nurse for 90 days. do what you have to for pt. safety.
my unit (where i still work as a pca - not done with nursing school yet ) hires new grads regularly. sometimes med/surg doesn't prepare you for the actual skills you need in that icu environment. they have a long orientation and a supportive staff and i don't see a problem with it. i know some nicus prefer new grads because they don't have any "bad habits" to unlearn from other units.[/quote]- end quote from lilpeanut
on a med-surg unit you will learn the basic skills of things that are needed in an icu setting though like how to prioritize care.i have seen many new grads that in addition to learning the documentation tools...they are having to learn prioritization of care.some.,..most new grads are so task oriented....ex:need to give meds with time constraint ( due at 1pm must give by at least 130pm), must do treatment due by 2pm ,...oh yeah...then i need to then go back and check on the lady that was having cp...........wrong prioritization of care!!!i am a big fan of med-surg experience prior to icu.but lets not make this thread about "new grads shouldnt be in a icu".
excellent idea to close to allow op time for reflection.i am worried about this situation...bc this op stated she'd have no problem administering 70 mg of haldol again. i am worried bc it sounds like the main concern was to "silence" the patients moans...and not treat the underlying reason of "why" they are moaning.one of the posters talked about eps developing with haldol use. eps isnt pretty and the patients are often left with them for life.pillrolling, lip smacking, shuffling gait etc etc ...these can be socially ostracizing for the patients. you can given cogentin all ya like after the fact but ...it will not do alot once eps has developed. and again....haldol isnt treating the underlying condition.
always think "what brought this patient to me?"- was it the wound infection and pain----if so treat that...and the moaning will reside.
what brought the patient to the hospital?- treat that!.in alot of icus....they are staffing with huge quanities of new grads who share this same op problem. she went to other nurses who obviously have minimal experience also that didnt stop this problem dead in its tracks. so...alot of this can be laid upon that same nm's shoulders who wrote the op up,.. who obviously isnt providing enough experienced nurses for resources for this new grads who are there to learn in her icu.when she hired thi new grad op...she accepted a responsibilty...both to the op and to the patients to make sure she /he had plenty of resources to pull insight from. was this nm more concerned over the budget(cheaper new grads) ...and not focusing on assuring her unit/ patient population had the safety / benefit of new and experienced nurses.?
my advice.....in an icu.....be very very leary of sedation. sedation to maintain intubation is one thing...you have abgs to draw every so often that can validate your oxygentaion or you can pop an etco2 monitor on. if...a patient is not on a vent.......it is walking a thin thin thin line when you opt to sedate. in a situation like that....always first just treat the problem that brought that patient to you....and when sedation is involved document that you clarified with the pharmacist(time date and name)...and ask the charge nurse to give a dose ever 3rd dose.....that way.....they cant say they were not aware.mistakes will be less likely to occur then. give yourself time and just use this a learning experience.i feel for you ..i do. i have a feeling from your posts that their isnt a huge resource pool that you can go to at your icu.....and that isnt your fault. i work as a icu nurse and charge nurse in a icu @ times....and it is my job...it is my job to check behind my nurses...esp the new grads who do need insight at times like this.so this op here....isnt the "sole" problem here.when that hcf hired him/her into that icu they accepted a responsibility to assist them until they reached the "expert stage" on benners stages of development. you cant fault him/her 100% for this....this op is probably tracking right along on benners stages of development where he/she should be. we'd all love it if all new grads could be spit outta nursing school as a "expert pratcitioner" on benners stages of development.
two ways of looking at this folks!
just wanted to reiterate this! i am also still concerned as to "why" this charge nurse wrote up this op....after...after....the nm had already done so...and after the nm had placed all the criteria for continuation of employment. i mean we have all seen "those" nurses who feel so darned bad about themselves they want to point out a co-workers mistakes till hell freezes over in a effort to make themselves look a lil better( warped isnt it?).i am sure the cn is still concerned.....but i think this op had already taken her lumps from the nm.i think this op now knows "if i am giving a drug more than 4 times in 4 hours(generally) they probably need to be on a drip...and to call the md back. i think thats probably clear now.i think the concept of laying the sedatives on a patient now means a lil more to this op too.it is a huge huge risk and i am not an advocate of it....unless its to maintain intubation,...or they are in dt's and well you know!
i can definitely see the cn taking this op aside and talking to him/her.....but another write up?i mean...it makes me a lil concerned about the environment this op is functioning in. i am....like the worlds biggest patient safety advocate.i made my feelings pretty clear to this op.that being said.....when hcf's hire new grads in high acquity areas they owe both the patient and the op an environment where the op has mentors he/she can reflect to when they have a question.lets not forget...this op stated she asked the cn and some coworkers prior to giving one of these drugs....and no one corrected her and stopped this.that...concerns me.
When I was in school our instructors warned us about taking a first job that seemed to be an usually great offer. There was one place that had a reputation for offering head nurse positions to new grads. That's not an easy job, its the sort of job that most places would want an experienced nurse to fill.
Why would they offer that kind of job to a new grad? It that case it was because no one else would have any part of it because of the way the facility treated its management people and the demands they put on them.
When I moved to Ohio, I got a great offer from a facility that was just overjoyed to get a nurse with 10 years of experience. I thought it was odd, but I needed a job right away so that I could get the mortgage on the house we'd agreed to buy. Found myself working as the only licensed nurse on a neuro unit with 3 GNs.
Obviously, I don't know anything about where you work, but I can't help but be suspicious of a place that would put a new nurse in a job that intense.
Yep. I was offered a great-sounding position as a Staff Nurse in a small rural hospital years ago, after my husband and I separated and I also needed verification of employment to get the mortgage for the house I was planning to buy. Well, after I started working, I was told by the Powers That May Be that I was going to be placed on the 3-11 shift as House Supervisor. I quit after six weeks and went to work for a local Home Health Agency, because not only was I lied to about my job description, but also because there were no viable after-hour child care options for my son, who was five years old at the time.
both were sentinal events, could have caused major harm...on the #1 situation, you would figure the person coming in after you would have questioned Q3h ativan...unless actively seizing...frankly, I would have called the doc (or at my facility, I would have called you first...),
we're all learning...even at 10+ yrs, we are able to learn something.
thank you for posting your situation, we can all learn from each other
Amen and ameN! Most of the new RN grads these days seem to lack...empathy and common sence. They come into the pts. and tell them things but without any feeling. Hard to explain, but it jumps out at me. I've been an LPN for over 30yrs so I've seen alot of changes. When I graduate and earn my RN, I will always strive to keep that loving bedside mannor that I've learned over the years....
As an "old timer", I still think that new grads should "do their time" on med/surg, advance up through tele, etc. Nursing schools today don't teach you to be a nurse, they teach you to pass the boards. I believe that new grads should not be in specialty units. I work the ER, and have seen some pretty incredible things done by newer nurses, not just new grads.
There is a confidence, a maturity, that comes with experience. No, I do not know it all...... I learn something new every time I come to work. But, I do know how things operate in other parts of the hospital. I have learned to develop a "gut"---that patient doesn't look right....that order doesn't seem right..... and that comes with experience. Hospitals today don't have the time nor the money to give you the proper orientation period that you need. By working a less acute area you can focus on developing your assessment skills. Yes, I still look up medications, I still confer with colleagues, I ask ask ask when I am unsure. That never changes.
both were sentinal events, could have caused major harm...on the #1 situation, you would figure the person coming in after you would have questioned Q3h ativan...unless actively seizing...frankly, I would have called the doc (or at my facility, I would have called you first...),
we're all learning...even at 10+ yrs, we are able to learn something.
thank you for posting your situation, we can all learn from each other
linda
True, and if it were MY family member that was dosed that heavily, I'd have gone beyond the hospital admin. to look into this. Furthermore, in the hospitals I've worked, the OP could be fired for attitude alone. Where is the REMORSE? The bottom line is PATIENT SAFETY. We have all made mistakes & felt sick about it. Just b/c you looked something up in a drug book will NEVER IN A MILLION YEARS hold up in a court of law. Take responsiblity. There is alot of very very good advice in these posts. Heed it. You will not LEARN if you run from this situation.
I've read all the posts, and I agree that the OP needs to look in the mirror. You cannot go thru life thinking you're smarter/know better than anyone else-- some people refuse to learn from mistakes-- hopefully it won't take a poor patient outcome to be a wake-up call. The day we can't learn something new is when we stop growing. The hospital is giving you a 2nd chance-- that you may not deserve.
I've read all the posts, and I agree that the OP needs to look in the mirror. You cannot go thru life thinking you're smarter/know better than anyone else-- some people refuse to learn from mistakes-- hopefully it won't take a poor patient outcome to be a wake-up call. The day we can't learn something new is when we stop growing. The hospital is giving you a 2nd chance-- that you may not deserve.
I hope...it is my hope anyway that when this OP wrote that he/she "would do this again tomorrow"...that it was written in haste...and doesnt truly reflect how they truly feel. I think/hope that he/she realizes the seriousness of the situation. There are very few times when you would actually go to the mid-high range of any sedation.When you do it is to treat the PRIMARY REASON for their admit.Like yes ...status epilect seizures, Acute DT's, etc etc etc.You always place patient safety first and foremost.
For all the other experienced ICU nurses out there reading this....take a long hard look at this thread.The next time you have a Newbie asking you to give your opinion on a drug/ a order/ a treatment...really listen .Without mentors situations like this occur.It really bothers me that this OP spoke to coworkers and the CN prior to giving this exorbinant amt of Haldol and no one.....no one stopped this event. We all talk about root cause analysis.....so lets do root cause analysis here. This OP.....in all their limited experience attempted to get coworkers and the CN's input prior to processing this vague/unlimited/very dangerously written order. It could have been stopped there....When pharmacy noted this order and made it available in Pyxis...it could have been caught there. There were numerous opportunities for this to have been stopped before...before that first amp ever made it into the OP's hands.Just to look at all angles here ...consider this .Not diminishing the OP's accountability one bit...just doing root cause analysis here@!
Perhaps, I missed something, but I do not see where the OP did get the Charge's input. In fact, I have asked that question, but do not recall it being answered.
It would be remiss to put the Charge monitoring the OPs medications, if the Charge had approved the Haldol dosing.
i also asked the other nurses on the unit, including the charge if it were ok that i give that much and noone said anything other then they had not given that much before but it didnt violate the order or the corecct safe doasge.- written by np2be on their initial post!
this should have been stopped right there...note that he/she stated other "nurses" as in plural....and that yep it included that charge nurse too!
this should never have happened....it should have been stopped by the cn....had he/she been actually doing their job.
) hires new grads regularly. sometimes med/surg doesn't prepare you for the actual skills you need in that icu environment. they have a long orientation and a supportive staff and i don't see a problem with it. i know some nicus prefer new grads because they don't have any "bad habits" to unlearn from other units.[/quote]- end quote from lilpeanut
TopherSRN
126 Posts
The OP obviously didnt learn anythign from this experience. As far as trusting the drug books, they are a guide. Personally, I would value an experienced ICU nurses wisdom moreso than a book. That book hasn't pushed the meds it has in it.
And I can understand you being worried about being fired for another med error. But that same med error could end a patients life. That should put things in perspective, but somehow I doubt it will. You were given a gift, yet you are pretty indignant about it.
My advice? Be glad you kept your job and have some humilty while taking advantage of your coworker's experience. And especially being in the ICU, hone your critical thinking and seek the rationale for orders/procedures instead of just blindly following an order and not questioning it (whether internally or actually calling the MD).