I went to work the other day, Cardiac ICU. And most of the nurses at my work do not do a bedside report. I often will go check the room just to see what state my patient is in, what drips they are on, etc. I saw that my pt's BP was 80 systolic, curious I looked at the lines, saw Levophed was hanging, and checked the bag...which read Azithromycin. Realized that there was no vasopressor hanging on this ladies BP. So even though I had not received report yet, I hit the hold button, and ordered a bag of levophed stat, grabbed the RN while she was still giving report and showed it to her.
This is an excellent nurse, often works charge and resource, has been around for 10 years and it happened to her. Same with the day nurse who is assumed to have hung the medication. And I, the nurse with a year experience, caught it.
It was reported and everything is going through proper commands.
Just wanted to share, hopefully it will help someone else from making the mistake. I often check all my bags multiple times during a shift, see how I'm doing on fluids and plan to reorder new bags early so I don't run out. But it can happen to anyone.
I wasn't looking for kudos, I am sorry if that came off in the tone. I have almost made large errors myself, and was just hoping someone could maybe see that any of us can make mistakes. The superstar RN's with 20 years experience to the new graduate with none.
I was an LVN three years prior, and I can tell you, the fear of making a mistake that kills a patient is what helps me, but I know that every day, especially an insane day on a floor can make you miss something big. We are all prone to doing it, bedside reports are not done everywhere, and I think they should be for reasons such as this, two sets of eyes are better than one. As the one person stated about teamwork, I find that infinitely important.
I grabbed the other RN because I knew nothing about the patient yet, I had yet to receive report. I set her blood pressure in stat mode, it was hanging in the 80 systolic, she seemed stable and because the line was marked levophed and the pump was set to levophed but had a zithromax bag hanging, I went ahead and ordered the drip stat. If the drip ended up not being needed, fine, but I would rather have it when I grabbed the RN, then not have it. Can you tell me what I should have done differently?
I also grabbed her because I know she would rather have me tell her, than hear about it in an incident report, she actually went ahead with the nurse assistant manager and filled it out together. I was trying to be as respectful as possible, because some day that will most likely be me. She would rather self-report, than have me report it, that's why I grabbed her.
We are supposed to do mandatory bedside report, but no one does. It has been covered multiple times at my work, everyone is aware, I am sure the reasons vary between the nursing staff. But your right, I should attempt to be more proactive at my work, as we all should.
The RN stated the zithromax had been hanging in place of levophed when she came on shift, as she had never changed the bag. That was the information I received from her.
Different incident with a different patient:
I also recently mixed the wrong medication myself. I had to hang Levophed and because the patient had not received it yet, it is much quicker to mix, versus waiting for pharmacy, I grab the vials out of the omnicell. I pulled out the med with syringes. Grabbed another nurse to check with me, she just glanced, said "ok" and walked away. I then looked at the vials again, as I've barely ever mixed levophed, and realized the wrong medication had been in the omnicell. I had the drip already to go, was getting ready to spike the line, and that awful horrible feeling of almost doom hit. It was a medication I had never heard of, but I believe the dose was probably a lethal one had I actually hung the bag.
The errors here? I didn't check the medication that came out of the omnicell, yes it was in the wrong container, but that's my job to check and ensure it is correct. I overlooked it.
My second check with another RN was not really done, I should have grabbed her to look at the vials. Unfortunately this patient was a very unstable one, and needed the levophed stat, systolic was in the 60's, and that I believe made me overlook things such as the right dose. I hope that it continues to haunt me.
So yes, I know what it's like to almost make an error, I was just so grateful I caught it before harm was done. Maybe that incident is what made me feel more diligent lately in double checking. Perhaps I should have just told or started with the second incident.
There are no pedestals, we are all human, that's why teamwork, as the other nurse said is so important.
Ah, I see the information has changed now. You never painted in your first post that you hadn't received report, you only mentioned bedside reporting isn't done and then you launched into a recital of all YOU had done.
But I have to be honest, there is still a condensending tone to your explanation. You try to drive home the point that mistakes happen to "the superstar RN with 20 years experience"as well as the newer nurses...why that statement? Do you think people who have 20 years experience don't realize they can make mistakes? I know anyone who I've worked with ( and I have some dear, dear friends and mentors) with that level of experience and they are well aware of that fact. I just keep getting the impression you're trying to rag on senior staff...and that bothers me.
You then jump to the fact that you spoke to this nurse personally instead of just writing her up....I would have expected nothing less. It is only a professional courtesy to speak to someone face to face when you find an error in practice. To just write someone up, well that isn't really professional in my book. And you did speak that the nurse before her was the one who hung up the drip...which again points to a PROCESS that needs overhauling.
You then asked me what you should have done differently....I listed quite a few suggestions. But again, I see you trying to back up your point about catching yourself before you'd made mistakes in the past. You discussed the issue with meds from the omnicell and how you didn't do a double check which may have led your patient into an even more critical situation. In that situation, you're placing the blame on yourself, again not realizing a PROCESS was at fault, starting with the pharmacy staff who stocked the med incorrectly.
Listen, I will NEVER, EVER knock a nurse for being conscientuous. Just not the right thing to do. But I challenge you, instead of trying to paint yourself in that positive light, look at the situation and try to CHANGE it. You again state the issue about bedside report, become an advocate and push for change. Gather some data on the benefit to actually carrying out bedside report, there are all kinds of nursing studies out there...can't find one on point? Offer to do your own study! Do an analysis of similiar institutions, see what they've done..network, get peer input. Go to professional conferences seeking information, I assure you, you aren't the only facility to face these issues. Get involved, then come back here and post your results. Seek out information instead of posting a warning to others..we ALL know (or should know) mistakes happen...it's how you handle the aftermath that gives your true measure as a nurse. Those patients are COUNTING on you to be a professional and recognize when something needs to change and then, not coming on a bulletin board site to look for kudos, but to be an instrument of that change. That is TRUE professionalism and the standard we must strive for.
ruby...i am honored. i truly struggled with this post for a bit and struggled with my own feelings. it was a hard one but i had to comment. you are my hero in so many ways, your posts on this board frequently challenge me in my own practice and cause me to reflect and try to be an instrument for change. i am truly humbled by your comment!
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
ruby...i am honored. i truly struggled with this post for a bit and struggled with my own feelings. it was a hard one but i had to comment. you are my hero in so many ways, your posts on this board frequently challenge me in my own practice and cause me to reflect and try to be an instrument for change. i am truly humbled by your comment!
You try to drive home the point that mistakes happen to "the superstar RN with 20 years experience"as well as the newer nurses...why that statement? Do you think people who have 20 years experience don't realize they can make mistakes?
In fact, at least when it comes to the impact of being interrupted while prepping meds, experienced nurses are more likely to make drug errors than inexperienced nurses (source, CE exercise). And while I suspect from my experience that this may be related to experienced nurses being interrupted more often, any nurse with any level of insight and reflecction, regardless of experience, is aware that they're able to screw up as easily as the next person. Certainly every time an alert patient points out that I've given the wrong med dose or the wrong med (which happened just last week, when I mistakenly replaced the PM antiviral with the AM med), I wonder how often my mistakes go unnoticed.
I think highlandlass makes an excellent point when she brings it back to system errors and away from personal responsibility. Though there are some cases when medical errors (of all kinds) are wholly or predominantly the result of an individual, in many cases they are at least partially attributable to system errors, including inadequate staffing and insufficient education.
To the OP: I think highlandlass has made some excellent suggestions. You CAN change the system to make it safer,. Perhaps you can form a working party with other nursing staff on how to improve patient safety and present your ideas to the unit. It probably wouldn't be a good idea to mention the specific incident though.
I forgot to say that on my ward we have a monthly critical incident review - our NUM presents stats on falls and drug errors, and focuses on either a specific incident or a trend. We look at what factors contributes to both the incident and the severity of the incident, on how it was or could have been minimised, and how we're doing as a ward.
With their permission, nurses involved in the incident are invited to contribute. A couple of months ago one of the reviews included a DD error and the loss of a fistula due to phlebotomy - I made and reported the first error, another senior staff member made the second, and we both discussed it in the meeting. It's important for less experienced staff to be aware that anyone can made an error, and that 'owning up' to errors is part of your professional responsibility - one that doesn't result in disciplinary action over change.
As a result of staff feedback on the second error we realised we were too reliant on patients protecting their fistulas, which doesn't work when (as in this case) you have a NESB patient with confusion, an agency nurse, and blood collection at the end of a frantic night shift. We implemented additional safeguards to resolve some of the contributing issues.
I think it is very good practice to look in on your patients before receiving report. I had once received report and right after my patient was found on the floor. I will never know if they fell before or after shift report. So the lesson I learned is, check every body first to make sure no one is on the floor and that bed alarms are activated if needed.
Also, another instance I recently encountered. I walked in to a new patient (after report) with respirations of 8/min. Now that was a very tense moment. The PCA pump was set wrong and this patient was overdosed. So now, along with checking fall risks and such, I'll check to make sure people are breathing right before I get that shift report.
The lessons learned in this profession are never ending. I'm so glad we can each come here to share our stories to help/teach each other.
In fact, at least when it comes to the impact of being interrupted while prepping meds, experienced nurses are more likely to make drug errors than inexperienced nurses (source, CE exercise). And while I suspect from my experience that this may be related to experienced nurses being interrupted more often, any nurse with any level of insight and reflecction, regardless of experience, is aware that they're able to screw up as easily as the next person. Certainly every time an alert patient points out that I've given the wrong med dose or the wrong med (which happened just last week, when I mistakenly replaced the PM antiviral with the AM med), I wonder how often my mistakes go unnoticed.
I think highlandlass makes an excellent point when she brings it back to system errors and away from personal responsibility. Though there are some cases when medical errors (of all kinds) are wholly or predominantly the result of an individual, in many cases they are at least partially attributable to system errors, including inadequate staffing and insufficient education.
I appreciate your including your cites in your post...always welcome in my book..it's amazing how many different citations there are out there! I find it interesting about the comment regarding nurses preparing medications. This is a topic I've read about recently..quite a few articles coming out. I am trying to restrain myself personally from interrupting colleagues who are preparing meds unless it's a crisis situation. I think as nurses, we need to be as firm about the med situation as we are about report. NO ONE will interrupt a nurse getting/giving report...because WE have set that standard. And as a profession, I think we do a darn good job with exchange of information. I think we now need to band together and do the same thing re: meds. I have been heartened by my facility...they have now trained clerks who answer phones to not bother nurses during standard med times: they take a message and then pass it on to the nurse. They explain to the caller the nurse is passing meds and we are committed to patient safety. The only calls put thru are emergency ones! I love this, it is giving nursing the professional recognition it needs as well as showing the facility as a whole is taking this topic seriously.
highlandlass1592, BSN, RN
647 Posts
Ah, I see the information has changed now. You never painted in your first post that you hadn't received report, you only mentioned bedside reporting isn't done and then you launched into a recital of all YOU had done.
But I have to be honest, there is still a condensending tone to your explanation. You try to drive home the point that mistakes happen to "the superstar RN with 20 years experience"as well as the newer nurses...why that statement? Do you think people who have 20 years experience don't realize they can make mistakes? I know anyone who I've worked with ( and I have some dear, dear friends and mentors) with that level of experience and they are well aware of that fact. I just keep getting the impression you're trying to rag on senior staff...and that bothers me.
You then jump to the fact that you spoke to this nurse personally instead of just writing her up....I would have expected nothing less. It is only a professional courtesy to speak to someone face to face when you find an error in practice. To just write someone up, well that isn't really professional in my book. And you did speak that the nurse before her was the one who hung up the drip...which again points to a PROCESS that needs overhauling.
You then asked me what you should have done differently....I listed quite a few suggestions. But again, I see you trying to back up your point about catching yourself before you'd made mistakes in the past. You discussed the issue with meds from the omnicell and how you didn't do a double check which may have led your patient into an even more critical situation. In that situation, you're placing the blame on yourself, again not realizing a PROCESS was at fault, starting with the pharmacy staff who stocked the med incorrectly.
Listen, I will NEVER, EVER knock a nurse for being conscientuous. Just not the right thing to do. But I challenge you, instead of trying to paint yourself in that positive light, look at the situation and try to CHANGE it. You again state the issue about bedside report, become an advocate and push for change. Gather some data on the benefit to actually carrying out bedside report, there are all kinds of nursing studies out there...can't find one on point? Offer to do your own study! Do an analysis of similiar institutions, see what they've done..network, get peer input. Go to professional conferences seeking information, I assure you, you aren't the only facility to face these issues. Get involved, then come back here and post your results. Seek out information instead of posting a warning to others..we ALL know (or should know) mistakes happen...it's how you handle the aftermath that gives your true measure as a nurse. Those patients are COUNTING on you to be a professional and recognize when something needs to change and then, not coming on a bulletin board site to look for kudos, but to be an instrument of that change. That is TRUE professionalism and the standard we must strive for.