Coping with mistakes

Coping with mistakes.

I think the thing for me was seeing how EASY it was to make a simple mistake. 

I was still being precepted when I gave the whole vial of Cardizem (25mg) IVP instead of the 10 or 15 the Residents had ordered.

Good news is, they were all watching and were astonished at themselves for how well their order worked as they watched the monitor and saw that HR dropping and settling in to a nice SR they could actually see/assess.

My preceptor had a suspicion though, cause she casually strolled into the room and queried me on the amount given. Once she confirmed, she yelled out the door to the residents as to what had happened. The Docs at first looked shocked, then sad, but only because they thought their order of 10 or so had worked like a charm.

No one got mad, or in trouble. But I never forgot that day.

Have I had med errors since? I'm sure I have but not one comes to mind. I can however remember a real near-miss. Scared the *** outta me. Near misses that you recognize can really help you in your strategies to stay safe. And those strategies are a form of coping.

The hardest thing I had to learn to cope with was death . I worked ICU. Took me awhile to figure out how to not self-blame.

I was just graduating from my ADN program in Seattle when the saddest story of med error hit the news.. it made me almost paralyzed in fear of a med error. (18yr senior nurse committed suicide after med error at childrens hospital) but I channel that fear.
I say the med order out loud and the 6 rights. I do not care if someone thinks I am nervous/unsure. I just want to be the safest nurse I can possibly be. 
also another wise nurse spoke up about med errors in a new employee orientation. She said every nurse has a med error because we are human! Humans run on autopilot- driving the same commute, taking our own personal meds, etc.. she also said there is a chain of people that could also help prevent errors. Like in the gut wrenching story of the Seattle nurses error, the RCA was determined the pharmacy sent a new vial with adult levels vs child dosage.. possible interruption during the med draw/verification process. 
I NEVER hesitate to ask/verify/ talk out loud when I collect my meds because I want the very best outcome for my pt and myself! 
Try to use that awful feeling to channel you and propel you to have an another level of healthy fear. Never forget the error but embrace the level of protection every time you pass meds. 
I hope that helps! 

3 hours ago, elleMrn said:

Like in the gut wrenching story of the Seattle nurses error, the RCA was determined the pharmacy sent a new vial with adult levels vs child dosage.. possible interruption during the med draw/verification process. 

Do you have a source for this?

@chare

yes, there are several journal entries but I don’t have access to them on my phone but here are some details from the investigation and heart wrenching outcome:

https://nurseslabs.com/remembering-kimberly-hiatt-casualty-second-victim-syndrome/
 

This didn't happen to me personally, but during a briefing before our first clinical in a hospital setting, we learned that a nursing student in another program had administered a fatal dose of digoxin to a patient in that hospital. She failed to check the pulse before giving it, and the patient went into cardiac arrest.

1 hour ago, elleMrn said:

@chare

yes, there are several journal entries but I don’t have access to them on my phone but here are some details from the investigation and heart wrenching outcome:

[...]

Thank you, but I am well versed on who Ms. Hiatt was, and what happened.  What I was asking for was a source for the claim that the  "pharmacy  sent a new vial with adult levels vs child dosage" as this is the first time I have heard this.  

Oh Orca, that must have been devastating- for you, your classmate and every single person that experienced that awful situation. 
I am sure we all have an experience with med pass errors and the only silver lining is that we grow and prevent others from a similar possible sentinel event. 
Nurses have to help each other and make it better! 
I think about the Seattle nurse- Ms. Hiatt, her years of devotion and her two teenagers that she left behind- every day since April 2011. May her devastating story teach us all. 

To the original nurse @J.Robinson011

please read this link:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4159062/
as it really highlights the PTSD of the second victim (the nurse). Your stress of the med error means you care deeply about your patients. Please don’t lose that precious feeling! and if you need even more help with coping, listen to one of my favorite pod casts about PTSD/carrying heavy bricks.

https://podcasts.apple.com/us/podcast/the-Dr-john-delony-show/id1527609854?I=1000527080113
 

I hope you find peace ?