Error

[Nursingstressed111]

I’m a relatively new RN only worked at the facility for 4months. The area in er that I work is team based so we don’t have our own individual patients. 

 Last week I went in to do an initial assessment of a patient that had come into the department that was drunk and had assaulted a few people on the community. The patient was already in 2 point restraints and had been sedated by either the triage nurse or Paramedics I can’t remember. I did her assessment noting the restraints but did not initiate restraint charting only charted about it on her initial assessment and included that she had restraints on and that I checked csm. I actually meant to go get the charting but I completely forgot and got distracted as it was incredibly busy in the emerg with many escalating mh patients Once the patient was awake a couple of hours later I removed one restraint and charted that on the chart. There was some charting in between but it was mainly about condition which was stable. 
 

I completely messed up it wasn’t until the next day that I remembered and asked one nurse about it and she said that she left very angry. 
 

Should I write an incident report about my error or talk to my manager about it? I know my actions were very careless and I’m worried about losing my licence.

[Guest219794]

Ask an experienced nurse where you work the best way to proceed.  

You can chart late about things you actually did.  

I have no idea about how this team based thing works, as every where I have worked, somebody has prime responsibility.  Your environment seems unusual, so ask somebody you trust how to proceed.

 

[speedynurse, ADN, BSN, RN, EMT-P]

If you are only 4 months in, you should be barely off orientation, right? In the ER I worked in, new grads received 3 to 4 months of orientation. Even once you are off, someone should be looking out for you. My ER also tried team nursing once. Yes it got tasks done but it was mass chaos - it’s like no one “owned” the patient or responsibility and less to frustration and confusion. It’s hard enough to “know” your patients in the ED but became even worse with the “team nursing”. Maybe it works for some ERs....just didn’t work for mine. Honestly I think yours is a likely mistake because when regular block assignments are not assigned to a particular nurse, these things can and do happen. Have you asked a coworker (mentor, former preceptor, etc?)

[JKL33]

On 10/12/2020 at 1:37 PM, Nursingstressed111 said:

I completely messed up it wasn’t until the next day that I remembered and asked one nurse about it and she said that she left very angry. 

The patient left angry because you didn't fill out some paperwork? I doubt it. Or your coworker left angry after discovering that some paperwork wasn't filled out?

So, help me understand. You were responsible to get the paperwork going for restraint checks according to department policy? And if no one has primary responsibility for any given patient, whose job is it to make sure each check is performed? Is all of that detailed somewhere or is it up to the team to figure it out every time the situation arises? Why wasn't the paperwork already rolling given that someone had already restrained the patient?

Be careful with your self-deprecation ("I completely messed up"). There's a difference between thinking about what you might have done differently and accepting responsibility for the the cluster that this is--which is a situation where someone restrains a patient without taking care of any of the attendant responsibilities of doing so, leaves them in a bed for you (or whoever) to find, in a situation where everyone is responsible for everything and therefore no one is really responsible (as it plays out). Meanwhile everyone is running around like chickens with their heads cut off, because.

I second the advice to check with a reliable party to figure out if there is additional charting about which you should make a late entry. And under no circumstance should this include anything that you didn't actually do.

[Melissa Davis, DNP, RN]

Hi, my heart goes out to you because you are in fact a second victim of your error, as we all are. My research is focused on nursing medication errors and I can tell you this:

1. You were probably given the message in school that, if you are smart enough and care enough, you will not make errors.  WRONG. 

2. All humans make errors continuously-- I just made two typing errors while writing this post.  It is not reasonable to believe that, as nurses, we will suddenly get perfect.  

3. What really needs to happen is: nurses need to be taught how to spot the systems risks that make it easier to commit the all-too-human and inevitable error.  We can then alter systems to reduce the risk of errors. I bet that, if we talked about your incident, you would find that it's somehow very possible to assess a client without remembering to start a restraint check log.  Imagine how different it would be if the signature area on your assessment reminded you to start the protocol, or even better, the EHR wouldn't allow you to finish documentation without starting the protocol.  Remember that as humans, we are rushed, we are distractible, we have migraines, , etc. -- all things that affect humans' ability to be perfect. We are not robots, a good thing,  but that also leaves us vulnerable to errors. 

4. Use this as a learning experience-- it's not win or lose, it's win or learn.  That's all you can do at this point-- and forgive yourself.  You cannot be blamed for being human. 

Anyone who tells you they don't make errors is lying.  I have 40 years behind me and have made plenty of them. 

I'm here if you need more support.  It's OK.  And I firmly believe you will NOT lose a license over this sort of thing-- if that were true, there wouldn't be any nurses left.  Check your state BON listing for cases in which licenses were suspended or revoked-- very often it's about unrelated criminal activity, such as DWI charges or other felonies. 

Melissa Davis DNP RN

[Hannahbanana, BSN, MSN]

There's a wonderful essay in the latest AJN on how experience and pattern recognition help a nurse to avoid making errors. There's no substitute for these, but it's important to keep your eyes open for them. Great read.

https://ajnoffthecharts.com/learning-on-the-fly-thoughts-on-birding-and-nursing-during-a-pandemic/

[Raven Sierra, BSN, RN]

This is why I HATE team nursing. Did it once - never, ever again. Everyone and yet no one is responsible, and, if your partner RN is lazy, you have all the patients and all the work. Ugh. Why this is even still used in any critical care area (including ER) is beyond me. But I digress...

Melissa Davis makes an excellent point above (#1). I will tell that to every new RN from now on, Melissa! OP, everyone has made mistakes. There's a mythos in nursing that the truly great nurses never make mistakes. That's bunk. I have an aviation background, and, let me tell you, even the best and brightest make mistakes...and, like in nursing, the mistakes that are made in aviation tend to have dire consequences. So the aviation industry made failsafes so human error is minimized - see the Swiss cheese model. Smart hospitals are taking up that idea - they've begun to realize that healthcare errors happens after a series of system failures, not just because of the nurse (who historically has borne the blame for failures). And many places have instituted checks so the errors are minimized (scanning meds, second-RN checks for high-risk meds, prompts in the EMR for critical things, etc.). In our EMR, the program prompts you to document on restraints.

I realize this is an old post, but I think nurses need to advocate for more checks like that built into our systems so everything does not rest on the often-hurried and short-staffed nursing staff to make sure no errors happen. As the patient overall acuity continues to rise and hospitals continue to staff at minimal levels (at best), we need everything on our side to keep our patients safe.

[doctordavism]

Raven Sierra, thank you for this.  We need more knowledge of these truths in the profession.  You are spot on, there is a myth that if you are smart enough and care enough you will never make an error.  That's bunk and frankly, I think that's a women's issue.  We ALL make errors every day.  Think... why would it be different as soon as you get to work? NO.  Raven, I think your experience and expertise about error puts you in an admirable position to work in quality/safety.  You may have a whole new career there!! 

 

[Raven Sierra, BSN, RN]

Doctordavism, I would love to work in quality/safety. I enjoy trying to see all contingencies and think through "what if?" scenarios. 

I had never considered this whole "no mistakes" myth as a women's issue, but, on further consideration, I think you're right. As I think about it, I wonder if some of our greatest struggles in nursing are related to the fact that, historically, nursing has been mostly female...I don't want to derail the thread, but do you know of any feminist analysis of nursing challenges that have been done?

[doctordavism]

Raven, I like the way you think.  You have the NLN Spirit of Inquiry going here!  I really respect that.  I'm interested in what you and anyone else on this site thinks about it being a women's issue... as in, "you'd better not err or you'll be fired and replaced.  You're expendable".  I also believe the 5 rights is a women's issue and woefully inadequate and misguided.  I have written about how the 5 Rights are Wrong... why? because they fail to incorporate the complexities of medication delivery and the entire system behind it. They are a simple linear construct which is maybe OK on a Tuesday morning as you administer a Colace... but if you almost make an error, as you know, it should be hailed as a warning and others warned, system adjusted.   The 5 Rights does nothing for that.  In addition, the 5 Rights follow a military "these are the 5 things I ordered"-- in fact, the 5 Rights describe the components of an order.  So the message is: if I ordered this, you'd better deliver.  We are also threatened with the 5 Rights and fired, as in "you didn't follow your 5 Rights". 

I am not a firey feminist at all, but the longer I examine issues in nursing, the more I suspect they are related to women's issues, yes,  

Consider the use of "orders" as a term... as in ordering us around.  Military.  It's a PRESCRIPTION and the nurse's role is actually to contact the provider to advise when the prescription needs to change.  It's a mutual arrangement. 

I'd love to talk to you more about this all. And I want to know what you think...??