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.
This post made me want to cry for you. We bust our humps juggling elephants and chainsaws for twelve straight. Any of us that have been at this for very long know EXACTLY what it feels like to do everything right, yet miss or are in fear of missing that one little detail among the thousands of little details we are supposed to execute to perfection each day.
This COULD have been a huge problem, had you not caught it. But you did. In the end that will look "good" in this little meeting you are supposed to have. Give yourself a break, take a deep breath, and take care of you. I hope you have a couple of days off to decompress. Have you contacted your union rep yet? You will want to have a sit-down ahead of time with him or her. I suggest taking a version of your post here with you, and having him or her read it. It's quite effective.
So, does this ICU routinely staff the unit this way?
Thank you everyone and thanks for the advice. I need to get over it and hoping to get it out of my system soon. I did contact my union rep and waiting for my manager to speak to higher ups. I am just upset because I just transferred here from another hospital a couple of months ago and I just hate how my first blunder had to happen so early in meeting them. It seems like this is how nurses break on the unit which is a little different from my old unit where people would come back if we were drowning but I guess everyone's different? I'm not used to going on more than a 30 minute break so it's been hard adjusting to people taking their "union breaks" and some. In the end, I blame myself, and will have to get over it. I'll keep you posted.
You made a mistake and luckily discovered it and corrected it before any harm was done so that is good. I think you are overreacting and fearing the worst. It would be unlikely that you would be fired. What I don't understand is why you feel the need to compare yourself favorably to other workers, putting them down for not being a super nurse like you. That comes off as judgmental and you said yourself you are new to the facility. Also there is nothing wrong with taking breaks, we are all entitled to take our breaks and it is up to management to make sure there is enough staff to allow people to get their breaks. If you lived in CA where hospitals are required to have break relief staff to ensure enough nurses to patients you wouldn't need to skip a break to ensure safe staffing! Why should nurses not be able to take their breaks and lunch periods? You seem to want to blame others for your predicament of making a med error, it shouldn't have happened to you because you are such a great nurse and if only others had skipped their break. Next time don't stop what you are doing to answer the phone, how about drawing the blood and filling out the label at the bedside, that should protect you from making an error.
The way I see it, they are punishing you for being honest. Having enough integrity to come forward after you realized the miastake should protect you from negative consequences. Shame on your employer if it doesn't.
The conditions you were expected to perform your job in were deplorable and unacceptable, and it put patients at risk of serious harm.
You are set up to fail in deplorable conditions like this.
The fact that YOU are being blamed is inexcusable.
If I were a patient on that unit that day -- or the loved one of a patient -- I would make damned sure the right people knew about the PERIL me or my loved one was subjected to. Absolutely inexcusable.
As long as nurses put up with this sh*t it's gonna keep happening, because management sure isn't going to be the one to stop it.
What the heck is your union saying about this? What are you paying them for?
STOP blaming yourself right now. Everyone on this earth has a limit as to how much they can do. You were way beyond yours, through no fault of your own. Anger would serve you a lot better than fear and sadness.
Specializes in LTC,Hospice/palliative care,acute care.
QUOTE>>> 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 are going to sit down and type up a rebuttal and include all of this information and make several copies. The first copy goes with you to the meeting and this your response to the write up. Don't forget to add a page where you accept responsibility and include the actions you'll take in the future so you don't repeat the same mistake.
Save another copy to have with you when you receive your next performance review.When that time comes add a comment that show that shows you have successfully prevented history from repeating itself.
I think it is only natural to feel some sort of sinking feeling when something we do is wrong, even if by accident! I think it is a horrible feeling to get called to see the manager (I think I still feel like I am called to the principals office!!!). I would hope that any manager would freaking stand up for her nurses!!!
You made a mistake and luckily discovered it and corrected it before any harm was done so that is good. I think you are overreacting and fearing the worst. It would be unlikely that you would be fired. What I don't understand is why you feel the need to compare yourself favorably to other workers, putting them down for not being a super nurse like you. That comes off as judgmental and you said yourself you are new to the facility. Also there is nothing wrong with taking breaks, we are all entitled to take our breaks and it is up to management to make sure there is enough staff to allow people to get their breaks. If you lived in CA where hospitals are required to have break relief staff to ensure enough nurses to patients you wouldn't need to skip a break to ensure safe staffing! Why should nurses not be able to take their breaks and lunch periods? You seem to want to blame others for your predicament of making a med error, it shouldn't have happened to you because you are such a great nurse and if only others had skipped their break. Next time don't stop what you are doing to answer the phone, how about drawing the blood and filling out the label at the bedside, that should protect you from making an error.
I don't think the OP was inferring any of the above. She's adjusting to a new unit, and taking responsibility.
I don't blame the OP one bit for wondering where all of her coworkers went. Breaks are necessary and I applaud unions for seeing to it that this is the "norm," but that doesn't mean the OP wasn't caught off guard by some really wonky staffing policies on top of the situational demands of really sick people being sick people in that given moment. It was a perfect storm, and ripe for an error to occur.
Just a patient but---Sounds like you were being pulled in many ways at once, Mistakes happen. Don't be too hard on yourself, at least you caught it and admitted to it, that says a lot about you. It irks me how much nurses are over worked. I wonder what has to happen for staffing ratios to change to a safe level. I hope everything turns out ok for you.
I can absolutely understand that you feel devastated as I would feel that way too. I hope that the hospital does see the system failure was the real issue.
Guttercat, ASN, RN
1,353 Posts
This post made me want to cry for you. We bust our humps juggling elephants and chainsaws for twelve straight. Any of us that have been at this for very long know EXACTLY what it feels like to do everything right, yet miss or are in fear of missing that one little detail among the thousands of little details we are supposed to execute to perfection each day.
This COULD have been a huge problem, had you not caught it. But you did. In the end that will look "good" in this little meeting you are supposed to have. Give yourself a break, take a deep breath, and take care of you. I hope you have a couple of days off to decompress. Have you contacted your union rep yet? You will want to have a sit-down ahead of time with him or her. I suggest taking a version of your post here with you, and having him or her read it. It's quite effective.
So, does this ICU routinely staff the unit this way?