Devastated on First Write Up

[RNtoThe3rd]

I did it. I made my first MAJOR mistake of my nursing career. I mislabeled lab specimens. JACHO mess-up. And now I'm going to get written up.

I realized it 1 hours after I did it. The unit was a mess. 10 patients, 3 nurses (Yes, ICU). 2 Nurses were on break. 1 patient was actively crashing with a nurse, a fellow and a resident trying desperately to throw a line in, the second nurse was getting an admission, and I was watching the 7 other patients. Between running for the crashing patient's nurse, answering call bells (did I mention the tech was on break and no BA?), and drawing my neighbor's morning blood work, the phone rings for our 5th admission of the night. Blood in hand, I ask them to hold so "I don't mess up my blood." Well, yup, I did it. I mislabeled even though I realized I was about too.

I cried on the spot. I was walking around the unit, checking on everyone's patients, when I realized I mixed the names up. My heart fell. I immediately look up the labs and only the CBC came in. I immediately told the doctors and the primary nurses about the mix up. I filled out an incident report and called the lab to see if the could write a note to ignore or cancel it. And then I went in the back room and cried. I never made a mistake like that before. I cried in anticipation of what would happen; I cried because I heard I was going to get written up.

My manager came in and I asked to speak with her privately. I told her what I did and the steps I took to correct myself. I found out today that I will need to meet with her again...this time with an union rep.

I cried again when I got home; I'm crying now as I type this. I am a good nurse and I know I'm not perfect. I should have been more careful. It just sucks though. When you look at next year's performance evaluation, you are going to see a big fat red marking about how I'm unsafe with patient blood. But you know what you are not going to see? You are not going to see that there were only 3 nurses on the floor. You are not going to see that, when on patient was crashing, I was able to throw in 2 #18s/start Levo/bag the patient/set-up an a-line for my friend. You are not going to see I was watching 4 patients. You are not going to see that a family member came back in and gave me a big hug and try to give me a keychain (because that's all she could afford) thanking me for setting her up with pillows and a blanket in the waiting room. You are not going to see that I eased a patient's mind about surgery for her heart transplant the next day by educating her and showing her pictures. You are also not going to see that the residents were thankful I caught some orders or that I was able to keep my own two patients alive. You definitely won't see my nursing friends thank me for helping nor the hugs I got from the family. No, you will just see "Unsafe." And this kill me.

Maybe I'm being bitter but I see it too much. Nurses who fly under the radar and get a satisfactory score by doing the bare minimum. They don't sit with their patients. They don't "think outside the box" and some take the short cut. Here I am, day after day, being nice to my patient and their family, going the extra mile, and going above and beyond for the good of my patient. I know my limits and won't take on more than I can chew--heck! I asked to take report later because I didn't want to mess up the blood. And I did. It's just so frustrating that when you get written up, you automatically look worse than the person who does nothing therefore has nothing on their eval except black and white. I'm so incredibly devastated that I got myself into this position in the first place.

Thanks for letting me vent.

[Lev, MSN, RN, NP]

(((hugs))) It happens to the best of us. Mistakes humble us. Learn from your mistakes and move on and you'll be better than before!

[blondy2061h, MSN, RN]

Shame on your facility for setting you up for failure like that and then making the incident report punitive to boot!

This is not a "major" error in my mind as you caught it before harm was done. A major error would be if there was a type and screen in there and the patient got the wrong type of blood as a result. That didn't happen. I don't say that to make you think of how bad it could have been. I say that to make you realize that you did the right thing, taking steps to right the wrong.

I I think your facility needs to really rethink how many people can be at lunch as a time, their ICU staffing, and how incident reports are handled.

[Red Kryptonite]

I think your facility needs to really rethink how many people can be at lunch as a time, their ICU staffing, and how incident reports are handled.

This x100. The situation you were in was ridiculous.

[cayenne06, MSN, CNM]

This was a SYSTEMS error. You did the best you could in a very difficult situation. The incident report should have prompted admin to look at staffing ratios and their policies regarding breaks/lunches. I am sorry this happened to you- it could just as easily have happened to anyone else.

[CardiacKittyRN]

So sorry this happened to you!! And I have to agree with others that this SMALL mistake was not your fault completely. Yes, you messed up, but in the grand scheme of what was going on, I think you did well! I'd like to see how your manager would have handled it :/.

Also- 2 nurses on lunch when y'all were already short? No freaking way. On lunch or not, I'm sure the break room isn't far away. On my unit, they would have heard the chaos and came running to help or someone would have been peeking their head in telling them they were needed NOW no questions asked.

[kgoode0919]

This is your management's fault, not yours. If this is how your unit usually runs, then you should do just that, run FAR AWAY!

[caliotter3]

When I was laid off during a downsizing instead of the nurse who slept during 75% of each shift, I, too, was upset and resentful. Spend some time wallowing in this, but not too much time. Just enough to get it out of your system. Then learn and move on. I only hope that you are not terminated like so many nurses who get canned after only one mistake. It seems the conscientious employees are always the first to get punished by the system. All you can do is to pick yourself up and do your best. Good luck.

[lindarn]

Nursing needs to go public with the **** poor, unsafe staffing staffing in their hospitals.

Hospitals here battles going on for patients. One of the hospitals has placed large bill boards downtown with the ER wait times flashed, that is updated constantly.

I have yet to see the staffing ratios publicized anywhere. THAT would be an important piece of information.

In Washington State, the student teacher ratio bill is barely squeaking by. It will set the maximum number of students that can be in each classroom, per teacher.

As i have stated many times, no one ever died because they could not do long division, or diagram a sentence. But patients are harmed, or almost harmed on a daily basis due to short staffing.

Nurses need to go public with this, and get the public on their side. Teachers to the parents all of the time when the School Board decides to change things in the classroom, without the teachers consent. Why can't nurses do the same thing?

JMHO and my NY $0.02

Lindarn, RN, BSN, CCRN (ret)

Somewhere in the PACNW

[LadyFree28, BSN, LPN, RN]

I hope you will have a meeting with union rep and speak on the conditions you were faced with that night...they should be asking management WHY this was allowed.

[CrunchRN, ADN, RN]

Get over it. You are a human being under tremendously stressful conditions. It will happen now and then. Nobody was harmed. If your manager is anything but supportive then shame on her.

[Mulan]

At least you realized it and let everyone know what happened. Think of what could have happened otherwise. I hate to say it, but some people might have realized it and not said anything.

It's a big error, but thankfully nothing happened. Nurses have done a lot worse.

People, including nurses, are only human and no one is perfect, even though nurses are expected to be.

Let us know what happens.

Keep your head up and keep on truckin'.