bad feeling

[birdie22]

I made a med error and its slowly eating away at me inside. I'm still a new grad, almost out of orientation. Last night, my preceptor came in the patient's room to hang tpn. He is the one who was actually setting up the IV machine. I was in the room with him doing other tasks (not that it makes a difference). So we are giving bedside report and its then, 12 hrs later, we notice that the tpn was running at 10ml/hr instead of 100ml/hr. I guess we just never noticed. I went in the room a couple times throughout the night and remember glancing at the machine, thinking 'everything looks good'. It was truly an honest mistake.

So I obviously feel horrible about it - we notified the docs to let them know. I know its a big amount, but its not like missing that tpn was life threatening or anything. I've obviously learned a valuable lesson here. I thought I was pretty good about double checking my IVs, but now I'm going to like a watchdog.

I guess the one thing that is making me even more stressed about the situation is the nurse I gave report to - to put it nicely, can be a bit OCD about things. I just felt her eyes were judging me the entire time and saying 'you idiot, you're a failure. you're in trouble now'. Dreading going back to work because I feel I will be in trouble with management. ughhhh, I just want this feeling to go away.

[Isabelle49]

You live and learn. Just glad the TPN was running too slow and not too fast. I noticed when working in hospitals that there were times that I was paying attention to what I was doing, but I was also doing tasks by rote and sort of looking through what I was doing. It's important to realize that even though you are doing something you could do with your eyes closed, you must really pay attention (I think our brains get bored and are often out to lunch while we work on repetitive, rote tasks).

[MrChicagoRN, RN]

Everybody poops...and everybody makes mistakes:

https://allnurses.com/general-nursing-polls/have-you-ever-593659.html

[Ruby Vee, BSN]

i made a med error and its slowly eating away at me inside. i'm still a new grad, almost out of orientation. last night, my preceptor came in the patient's room to hang tpn. he is the one who was actually setting up the iv machine. i was in the room with him doing other tasks (not that it makes a difference). so we are giving bedside report and its then, 12 hrs later, we notice that the tpn was running at 10ml/hr instead of 100ml/hr. i guess we just never noticed. i went in the room a couple times throughout the night and remember glancing at the machine, thinking 'everything looks good'. it was truly an honest mistake.

so i obviously feel horrible about it - we notified the docs to let them know. i know its a big amount, but its not like missing that tpn was life threatening or anything. i've obviously learned a valuable lesson here. i thought i was pretty good about double checking my ivs, but now i'm going to like a watchdog.

i guess the one thing that is making me even more stressed about the situation is the nurse i gave report to - to put it nicely, can be a bit ocd about things. i just felt her eyes were judging me the entire time and saying 'you idiot, you're a failure. you're in trouble now'. dreading going back to work because i feel i will be in trouble with management. ughhhh, i just want this feeling to go away.

as med errors go, that's not a bad one at all -- better to give too little tpn than too much! we all make mistakes -- anyone who says they don't is either lying or too stupid to notice.

but about that other nurse -- since you have absolutely no idea what she was thinking, don't project. unless, of course, you have mindreading powers i don't know about.

[Roy Fokker, BSN, RN]

Heh! Reminds me of this...

You should read the whole thread in any case.

Know that you're not alone. We've all been there. At some point in our careers.

The two most important teachers in life are Success and Failure. To grow as a professional (and as a person), it is important that we learn from the both of them - for they both teach us important lessons.

To err is human.

The best thing to do is strive to not make the same mistake TWICE. :)

- Roy

[Penelope_Pitstop, BSN, RN]

I'm going to pretend to be that nurse to whom you were reporting.

I'd be kind of ticked myself.

Not at YOU, but at the fact that this had slipped by TWO nurses, one of whom was precepting (and if you ask me, it was his error because he programmed the IV pump!)

And, to share an anecdote that is similar, a very experienced nurse on my floor hung a new bag of heparin but forgot to hit the button to start the infusion. Of course, this wasn't noticed until a few shifts later....so, similarly, it went past a few set of eyes (and the most experienced was the one who made the original error).

Guess what? The patient was okay, and this mistake was, in comparison, much more dangerous than yours.

And you know what else? No one looks at this nurse and thinks, "oh my goodness she is a fool!" or anything like that. I only remembered it because of your situation.

Chalk it up to experience!

[RFRN]

Oh and remember- "I didn't kill anyone today!!!" Perspective when it all hits the fan.

When I was in nursing school, we did an interview with an experienced nurse. She told me it was a good day when everyone got their meds (even if it wasn't on time) and nobody died. I really think this is how you have to look at things. Did anyone die or get seriously injured? No? Well, then you learned your lesson and now it's time to move on. Making mistakes is how we learn so as long as everyone ended up ok, a mistake can be a good thing.