As nurses we take a tremenous responsibility upon ourselves & I made a mistake

DidiRN · Feb 22, 2005

EVERYONE makes mistakes and you have obviously learned from it. I would worry if you didn't get upset over it. Now go ahead and forgive yourself and move on, girl :) . Sounds like otherwise you did a great job for floating in the unit.

BTW, I thought his K might be less than that, not too bad really.

I got pulled to CCU yesterday, the charge said they asked for me specifically because they knew I could function and they were slammed. I had two patients. My new admit was an 87 y/o WM with CHF exacerbation, ejection fraction of 17% and bilateral pleural effusions. He came from the ER with a nitro gtt @ 5 cc/ hr which I'm not used to but there was no titrating needed so I was fine with it. About 3 hours after admit his BP was 96/48 and since it slipped to under 100 I turned off the nitro. Asked the charge nurse about it and she agreed.
The cardiologist then came in and ordered Dopamine/Dobutamine both at 2mcg/kg, the patient was 143 pounds so I set them both up at 10cc/hr. Then he ordered a lasix/diurel gtt. The order was 10 mg an hour. The med came up from the pharmacy and was labeled 10 mls/hr (25 cc) I took that to mean dose 10 mg per hour to run at 25cc/hr. It ran at 25 cc an hour for 6 hours and he was diuresing about 350-500cc/hr. The charge nurse was like "great" I wish my patient could do that.
During report I told the oncoming nurse that the lasix was running at 25cc/hr and she was like why? I told her. She said I think that's wrong, lets go look. It was of course wrong. The charge nurse didn't seem upset, she just said lets turn off the lasix for a while and 2 of the other nurses were like "it's ok, really". I said lets check his K (he was c/o leg cramps) the K came back 3.5. I immediately filled out an SOE on myself, the onconing nurse said she would call the doctor and just let him know as a courtesy. Everyone was like "really don't worry, it's fine".
I realize that the patient will be fine, but it scared me and I can't seem to get over making that mistake. I try so hard to be so cautious, my employer knows this, I'm in no way in fear of my job, but it brings me back to the reality of how much responsibilty we as nurses take upon ourselves. What if I had made this kind of mistake with the Nitro? That really scares me. I did learn an important lesson. If two rates are listed, choose the lowest and then call the pharmacy for verification. I now realize the (25cc) was how much lasix they put in the 250cc bag because that would make it 1:1 right? How do you get over being afraid of making a mistake or forgiving yourself for making one?

NurseyBaby'05, BSN, RN · Feb 22, 2005

Oh man! Things like this are why (as bad as my senioritis is) I'm scared to start working as a nurse. My liability as a brand new nurse is the same as someone more "seasoned." I also know that making mistakes along the way is inevitible, but sheesh. I feel like this :eek: :barf02: whenever I think about being out there on my own.

BTW, the way you handled the error was admirable. You realized you mistake, remedied it and documented it.

:flowersfo Hope these make you feel a little better.

begalli · Feb 22, 2005

The thing I like about our pumps is that you can enter the concentration of the drip and the patient's weight. The pump calculates the ml/hr. For lasix of course we don't need the weight, but for something like ntg, epi, neo, dopa, or whatever, it's really nice. As the infusion is running the dose (eg: 5 mcg/kg/min) continuously runs accross a screen on the channel like a ticker tape sorta thing.

Sounds like your patient got some good diuresis! I'm also surprised the K wasn't lower. What's done is done. Time to move on, but I do sympathize with your feelings!!

begalli · Feb 22, 2005

Then he ordered a lasix/diurel gtt. The order was 10 mg an hour.

I'm curious...I've never heard of a lasix and diurel gtt. I thought lasix would precipitate with just about anything and I've never seen two IV gtt drugs like this mixed together in any bag.

I now realize the (25cc) was how much lasix they put in the 250cc bag because that would make it 1:1 right? ?

If ONLY lasix was in the bag and the concentration was 1:1 then the bag should read 250mg/250ml (250mg of lasix would be in a bag of 250ml diluent [NS]). 10ml/hr would equal 10mg/hr. Perhaps the 25cc was really the concentration of lasix 250mg/25cc that was drawn up by the pharmacist from a vial and added to the diluent bag for continuous IV infusion. Does that make sense?

medpsychRN · Feb 22, 2005

I have to be honest, I had difficulty figuring out what you were talking about! Meaning, I was made aware of how little I know and if I was in CCU, I'd be in over my head in about 30 seconds!

You sound like a pretty smart person and I admire you for your willingness to accept the challenge to be pulled to another unit (CCU no less). I believe that unless you're pulled to a similar unit (e.g., med-surg to med-surg) mistakes are an opportunity waiting to happen and I'm sure management is aware of this. So, I believe this was an unfair assignment.

That being said, I do understand how you feel as when I make a mistake, no matter how small, I spend time ruminating about it, beating myself up. Probably related to that old nursing instructor I had who was more like a drill sargent. Regardless, I'm aware people are going to make mistakes no matter how careful. It's the people who make mistakes and aren't aware of them (or feel no remorse) that are the ones to worry about. Forgive yourself, move on. You're still a great nurse.

DutchgirlRN, ASN, RN · Feb 22, 2005

I've been at the hospital for over 3 years and very infrequently do we get an order for lasix/diurel (hctz) drip on the floor but it's always the combination of the two. As for the (25cc) appearing on the label I really have no idea but when I work Thursday I will be sure to ask. I cannot imagine a nurse who would not take responsibility for her mistake and fill out an SOE. That's a true coward in my opinion. I agree that makes for a very scary nurse and probably cold-hearted too.

Tweety, BSN, RN · Feb 22, 2005

Some of life's best and unforgotten lessons are from the mistakes we made. The key is to learn and grow from them. :)

DutchgirlRN, ASN, RN · Feb 22, 2005

Thank you Tweety you are so absolutely correct! I learned a valuable lesson that I won't forget.

robert7129 · Feb 25, 2005

It is normal to beat yourself up over this kind of error, but I don't know a nurse who hasn't made a med error. As long as we are human, we will make errors. I would encourage you to use this to improve your hospital's systems, which contributed to your error.

The labeling from your pharmacy should read "run at 10cc per hour." I would suggest this to prevent future errors.