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.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
You have a union? That is very good news. Please ask your rep if you have anything like an unsafe staffing report. Please ask the rep to educate ALL the nurses and managers about the appropriate use of this form. This form is like an incident report, even if there is no actual incident. It's just documentation that staffing levels cannot ensure patient safety and care. Unlike a regular incident report, it cannot be buried by management because copies go to the union and to whomever licenses the hospital.
Management will use all means to dissuade nurses from completing these forms. It outs their unsafe staffing practices. And you already know when you make an error due to unsafe staffing, your working conditions don't factor in, just that you were the terrible nurse who made an error.
You all deserve your breaks, and you deserve safe staffing. Advocating for yourselves is essentially advocating for your patients. Please talk to your union rep about unsafe staffing reports. Good luck to you.
OP, this is a process error. Repeat it, THIS IS A PROCESS ERROR. You were set up to fail, plain and simple. You did not cause patient harm. You realized your error.
Speak with your union rep about this. The conditions were unsafe. "As my record shows, I am a nurse with a spotless reputation, and prudent practice for multiple years. This was a perfect storm, which put my practice at risk, and an error was made. Thankfully, it did not cause patient harm. This needs not happen again, and I would like to discuss ways in which going forward, we can assure that it does not."
Then turn this around on your ideas on how it won't happen again. There needs to be more than one aide, one of which "spots" the other for breaks. By answering the phone. Heck, in some facilities the lab comes and draws. And if there's a house supervisor, that person needs to be more present in the ICU, especially when there's people on lunch. Finally, there needs to be labelling by the person who draws at bedside. The labs don't leave the bedside until they are labelled. So if there's a way to have labels at every bedside, that would be awesome, however, never take labs out of the room unlabeled.
Finally, there needs to be more nurses. Which is the issue with many, many facilities. They all try to do more with less. And at the price of a nurse's sanity and practice.
I don't mean to be bold (or perhaps I do) but it was not as if you were playing internet games, and mislabeled the blood due to your need to get to the next level of candy crushing. You did not label the blood and then think "gee, was that patient even SUPPOSED to get labs?!" But would've/could've.....The FACILITY needs to be held accountable for the conditions that they put their nurses in.
And I would be crystal clear on your record, and their staffing issues. Everyone on their end is going to play cover butt, however, you need to stick to the facts, be firm in that this was not a practice issue but a process issue, and be sure that you listen to everything they have to say, ask for a few minutes to review with your union rep, and as unemotionally as you can state the facts of the shift that lead to this process issue error as a response.
I wish you nothing but the best. Please keep us posted.
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.
THIS. And remember, after 6 years as a critical care nurse, OP, they can hire 2 of you for what you are being paid. Always have in the back of your mind that, in fact, sometimes they are less concerned about the error, and more concerned about "is this enough to let the seasoned nurse go, so we can get a couple more instead?" Which says absolutely nothing about your practice.
Wow that seems excessive to fire you over mislabeling a lab specimen. I've worked in dozens of ICUs as a traveler and this is a problem for each unit, in every hospital! It is tracked yes, but I have never heard of someone being fired for this. But no matter where you work, you will be written up for this. It is usually the lab in my experience that reports it. I don't see how one write up will effect your performance eval as a whole. That sounds ridiculous.
Do you print a rec and send along with the labeled lab specimen? This would prevent the lab from running a mislabeled specimen as they check it against the rec. And I can tell you that it doesn't matter what is going on in the unit, if you label at the bedside against the patient's armband, it doesn't matter. I'm just telling you what your management will say.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
OP, this is a process error. Repeat it, THIS IS A PROCESS ERROR. You were set up to fail, plain and simple. You did not cause patient harm. You realized your error.
Speak with your union rep about this. The conditions were unsafe. "As my record shows, I am a nurse with a spotless reputation, and prudent practice for multiple years. This was a perfect storm, which put my practice at risk, and an error was made. Thankfully, it did not cause patient harm. This needs not happen again, and I would like to discuss ways in which going forward, we can assure that it does not."
Then turn this around on your ideas on how it won't happen again. There needs to be more than one aide, one of which "spots" the other for breaks. By answering the phone. Heck, in some facilities the lab comes and draws. And if there's a house supervisor, that person needs to be more present in the ICU, especially when there's people on lunch. Finally, there needs to be labelling by the person who draws at bedside. The labs don't leave the bedside until they are labelled. So if there's a way to have labels at every bedside, that would be awesome, however, never take labs out of the room unlabeled.
Finally, there needs to be more nurses. Which is the issue with many, many facilities. They all try to do more with less. And at the price of a nurse's sanity and practice.
I don't mean to be bold (or perhaps I do) but it was not as if you were playing internet games, and mislabeled the blood due to your need to get to the next level of candy crushing. You did not label the blood and then think "gee, was that patient even SUPPOSED to get labs?!" But would've/could've.....The FACILITY needs to be held accountable for the conditions that they put their nurses in.
And I would be crystal clear on your record, and their staffing issues. Everyone on their end is going to play cover butt, however, you need to stick to the facts, be firm in that this was not a practice issue but a process issue, and be sure that you listen to everything they have to say, ask for a few minutes to review with your union rep, and as unemotionally as you can state the facts of the shift that lead to this process issue error as a response.
I wish you nothing but the best. Please keep us posted.
Thank you to all the nurses and people who responded; I was very emotional when I wrote and I thank you for taking the time to help me step down from the ledge and breathe and regroup. I do just need to relax. I apologize to the one who I thought I was coming off as judgmental as I never had the intentions to make it seem that way. I just more so wanted to hear how other nurses rebounded from their first write up. I also was trying to convey to how unfair I think is that WE ALL as nurses (not just any one individual) go out of our way and do great things and yet we do not receive credit for it on our evaluation; the one slip up is the thing that get us and not the 1,000,000 things we did great. Please know, I was not trying to say I alone am a "super nurse" because I view what I did that night as acts what any nurse would do (just not the slip!). I am my number one critic and I was beating myself up about doing something wrong and I do realize my mistake but I'm now seeing it could have been a staffing issue--but I still have to be more careful :) I was just frustrated by the fact that my co-workers have made a pact to go on 2 hour breaks (1 hour longer than the allotted time)...hence the quotes around union break when I commented earlier. I do believe in breaks as we are under stress as nurses but to take advantage of your co-workers I feel is unfair. I don't do their break which makes them nervous I will tell. The other night they got caught doing it so now there's another issue that I do not wish to keep commenting on in this post because in the end, I made the mistake, not anyone else.
Thank you for all the support, tough love, love, stories and just being a nurse. I really love our profession and still happy I chose it after 6 years! I think nurses are vital and smart in our healthcare system and I did not make a smart decision--I hate the fact I added a negative statistic to nursing. I just want to do us good! I will be more careful and speak to my union rep about my punishment --who said my manager cannot fire me since it's my first offense. Graci!
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.
You took the words right out of my mouth!!
Definitely a systems error.
I appreciate all the supportive responses you've gotten and I didn't sense any "superiority" snottiness coming from you.
Specializes in Infusion Nursing, Home Health Infusion.
The fact that the manager needs to meet with you again and asked you to bring in a union rep makes me suspicious that they want to write you up for the mistake. The punitive nature of nursing has always been a part of the profession that I have detested! What also makes me sick is that they never seem to put an error in context to the situation and lately seem to take a patient's or family's version of events over their staff member's account of the incident.
It is no surprise that an error was made in the chaos of the situation. As a matter of fact in writing up the error I would have extensively documented all that was going on and boldly stated that due to the severe lack of safe staffing an error that you would never have normally made occurred. You are still taking responsibility but you are explaining the situation you found yourself in that caused the error. Instead of the focus being on you so much it would be on the situation that created it! Its like in court when they place the blame on the the parties involved by percentages. By all means take responsibility and make that clear but also make it clear why it occurred and have suggestions for the corrective action you can take as well as management.
You should always label any blood or other specimens at the bedside . I see nurses skip this step all the time and take the blood out of the room to label it . I draw blood all the time and nurses want me to hand it off to them to label out of the room and I refuse to do it.....not happening! One of our nurses recently did this and the nurse she handed it to in the ICU mislabeled it and guess who got blamed...the nurse who drew it and handed it off!
I agree in the scheme of things this was not a big error because you caught it and if it had not been run yet I would have told lab to just toss it and I would resend it. If it had been processed already then I would have. Try not to fret too much...you sound like a good and caring nurse that is in a profession that still does not know how to constructively deal with mistakes by healthcare professionals. There is a better way that may hospital systems have embraced but not enough of them!
I used to go home after wok and like have these waves of panic as I was falling asleep that I forgot to do something...or screwed something up and forgot it. It was awful. I would jump up out of bed and call the unit at like midnight....Some of us just live and die by trying to be perfect. I will say whenI switched to psych I felt much more relaxed. Maybe that sounds odd, but while the mental stress of dealing with psych is intense, I do feel I have more time to make sure I am doing things correctly.
Please hang in there.. And I would say tell your head nurse next time you are short staffed like that you need to know who to call RIGHT THEN to get help. I would always throw in "patient safety" as my reason. And document staffing levels. And remember everyone has a boss. You have a chain of command. When I worked med/surg I would call my head nurse at 2am and say "ok...we are short..either you come in and work or get someone here". If you do not feel it is safe let someone know so you can at least say you did something. I think it will be ok...just learn from it as best you can. We are all human and even though we are working hard and paying attention..these things can happen.
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.
Listen, I am not trying to make excuses for you or to have you step away from whatever your part/responsibility/accountability is in this thing. Nonetheless, we have to be realistic and include vital information, which is quite relevant if Risk Mgt is going to do a true Root Cause Analysis.
7 patients in an ICU, which are left in your care/charge, is outrageous, period. I've worked it for many years. I have worked pediatric ICUs and such as well. 3 can be incredibly dangerous; depending on acuity, which often is ever-changing and considering a host of other factors.
Bottom line to me is this. Sure, you have to take what is yours, but under the circumstances, I'd say that you are damn lucky you didn't make a worse mistake.
Please write this up carefully on your computer, including all the relevant, factual information and circumstances. Step back and present it as objectively as possible. If you don't know, look up what is or should be involved in a RCA. Look up your institution's policies re: RM. Contact the RM person and ask to speak with him/her. Document as thoroughly as you can--again, presenting, as objectively as possible.
Do NOT beat the crap up out of yourself over this. Again, I truly feel like under those circumstances, it very well could have been worse. Just a very unsafe situation/environment--at least during the time you described.
You may also want to evaluate how administration assesses and works this up w/ RM, and then you need to see if this is an environment you really want to stay in. You worked hard for your license, and I am sure you don't want to be on the giving end of less than stellar practices--and the consequences of regularly functioning under them.
You can learn for this mistake, but if the situation was, in the critical care setting, as bad as you presented, well, even the most careful of nurses and docs can easily make mistakes. Sad thing is when people then run around looking for scapegoats. Don't be the scapegoat.
Yes, we need to be careful in labeling labs, but I am an expert practitioner, and honestly, I have made a few mistakes over 20 some years than could have killed a couple of patients. Thankfully I caught them before any crap really hit the fan. Sometimes, even as bright and diligent as one can be, well, at least for me, I've just had to thank God for looking out for me when things got crazy or stupid for one reason or another. There is also this little alarm that goes off inside of me, and that has helped me in avoiding bad consequences with the situations I refer to, as well as with catching things that had nothing to do with me--just stuff that people missed or docs missed b/c of utter craziness. We are there as a team, and we have to look out for each other. It's never one of those weird superior nurse things that some nurses do; like "Ah ha! I got you!" It's just more of being a reader and analyzer and then this intuitive thing--I guess mixed with experience. But my first priority is to the patient--and peds, that includes the family as well. Still, we just have to be a team, or life sucks for everyone.
I would like to tell you that you will never make another mistake, but that would be a total untruth. If you work long and hard enough, in enough wild environments, yes, human error will be a factor. But this particular situation set you up for the error--again, if what you shared is true.
After you have documented well and as thoroughly and objectively as possible, look, carefully communicate with manager, RM person, etc, and see if they are going to be looking to scapegoat you, or to truly do a fair analysis and correct the factors that led up to the error. They may say one thing, and then do another, so you may want to check your HR file and the NM's "secret" or open file, and whatever RM has written. People just have this whole, pass the buck kind of thing. The loss of that integrity in the workplace happens, sadly, more than enough. Your shop may not be that way, but on the other hand, eh. If they do not strive to be truly objective and work on correcting the "set-up" that was in place ASAP, well, then you need to start looking elsewhere for another position. Seriously. You don't have to tell them. Just start doing what you have to do. If they are that short, and if you have been a bright, conscientious nurse, they aren't going to fire you--unless someone is demanding a head to roll or a scapegoat. They might try to slap you on the wrist with something too; but just make sure on whatever form/s they give you, you put your addendum in of what transpired, and that it's noted that your addendum is added w/ your initials. Administrative records sometimes have a way of being there one minute, then being gone the next, and then returning. Oh I could tell you some stories I have seen over the years.
Hang in there and protect your license and livelihood and professional reputation.
PS. Sadly you will usually find some people that don't really work and focus enough on their patients and job that fly under the radar. You can see them in any field. It's just extra annoying in healthcare; b/c people are, well people, and not widgets.
Some number of them schmooze w/ docs and stand around talking about other people or something stupid. And some people are just downright unethical w/ their horizontal violence and sabotage of other nurses. I have actually seen where nurses have changed ordered heparin rates on pumps or other meds--unethical, but I swear to you this kind of thing can happen. You learn to make sure you are really checking everything every hour or more frequently--depending. You make sure that you take the time to document that carefully. I have seen some weirdo stuff--some of it mean sick and mean-spirited. Thank God in heaven this is not most nurses or docs. Thank God most of them have scruples.
I have seen lazy nurses in recovery areas or ICU that just don't document vitals at anywhere near the appropriate times--some people just think they will always get away with that and the patient will never have a problem in the next hour, where you now have to explain why the post-op admission assessment and VSS and gtts, etc were not recorded. They fire some nurses for being busy and missing a few things here and there, yet other people that are blessed with being in the posse have their poor practice ignored over ad over again. It's great when the NM are in on this too. Lack of scruples in leadership. And again you want to say, "But hey; we are dealing w/ people not widgets!" But then it still falls on deaf ears; and you just learn to be ultra careful over every little thing--especially in the ICUs.
There are a lot of games. You have to find ways to rise above them that won't get you singled out regularly--or you have to smile, do your job, cover your orifice, and go home and send out feelers or responses to other jobs on the down low. Sometimes unions help, and other times they don't--especially when they are just as corrupt and in bed with the hospital as all heck. And then you learn that the cliche' "Money talks, BS walks is this tragic reality."
TriciaJ, RN
4,328 Posts
You have a union? That is very good news. Please ask your rep if you have anything like an unsafe staffing report. Please ask the rep to educate ALL the nurses and managers about the appropriate use of this form. This form is like an incident report, even if there is no actual incident. It's just documentation that staffing levels cannot ensure patient safety and care. Unlike a regular incident report, it cannot be buried by management because copies go to the union and to whomever licenses the hospital.
Management will use all means to dissuade nurses from completing these forms. It outs their unsafe staffing practices. And you already know when you make an error due to unsafe staffing, your working conditions don't factor in, just that you were the terrible nurse who made an error.
You all deserve your breaks, and you deserve safe staffing. Advocating for yourselves is essentially advocating for your patients. Please talk to your union rep about unsafe staffing reports. Good luck to you.