hi my name is julie. i have been a nurse for 15 years and have loved almost every day. i can easily say it is my passion, however, less than a month ago, i made the first and only med error of my 15 year career. i hung a med that looked like pcn, but was not. it was a cardiac toxic drug and resulted in the almost immediate death of my beautiful pt, and the end of my life as ive known it. my spirit is broken, my ability to take the next breath, severely challenged. and the internal battle against the thoughts that are there to defeat and destroy me are constant.
i am feeling desperate to connect with anyone who has lived through this same horror. i have been trying in vain for over a week to find some way of linking up in a support group for nurses trying to get thru something like this. of the 310,000 med errors in this country last year, 7000 were fatal! where are all those nurses?!! are they all suffering alone like i am?
PLEASE, IF YOU HAVE BEEN THRU A SIMILAR SITUATION, CONTACT ME. I BELIEVE WE CAN HELP EACH OTHER SURVIVE IN A WAY OTHERS MAY NOT BE ABLE TO UNDERSTAND. i am outraged that a support network does not exist for these nurses even with documented sucides reported.
any suggestions? thank you and i am so sorry for the somber theme. julie
The med error that you are talking about, "went to hang pcn but it was another drug", sounds like what happened at one of the other hospitals in my town.
In other words, the hospitals do not have anything that resembles the kind of quality systems we use in industry, where errors like this are pretty much impossible. (If they happen, they don't happen more than once because we fix the underlying root cause.)
Factories process thousands or even millions of "widgets," from multiple product families. Each requires different processes and process recipes. Widgets don't get the wrong processes (~ wrong meds, wrong operations) because we have traceability systems and production tracking systems.
We also have safety systems. As an example, it was possible to hang the wrong drug on an IV unit but it is not possible to connect a hydrogen line to an oxygen tank (or vice versa). The connections are designed to be incompatible because connecting oxygen to a line that contains hydrogen, or vice versa, can cause an explosion.
If you give me five malpractice cases, or five cases in which a nurse is "written up" for making a mistake, I can probably show in at least four cases why the hospital administrator(s) and not the doctor or nurse should be disciplined or even let go.
I made a serious med error once, by the grace of God it did not result in death. I was assisting a resident placing a central line and handed him a syringe filled with lidocaine instead of saline for a flush, then heard the words we all dred from the patient "I don't feel good"... she went into a temporary cardiac block and recovered, the doctors were very supportive. I was a wreck, I seriously considered quitting nursing for a long time, my hands trembled when I did meds for awhile. I talked it over with close friends (not nurses). I finally found forgiveness from one of my close friends, who basically told me "how could I as a nurse expect to never make a mistake!" He is right, as nurses we expect that we will never make a mistake, it is not in our culture, we have no avenues to help us deal with the fact that we are human and we will make mistakes. I think doctors are taught that some of their patients will die as a result of their mistakes, they seem to be able to handle it better than we do as nurses.
I think this is an important line of discussion. I decided to continue in nursing and I learned that ALL of us can make a mistake, and it has made me a better nurse, I always give myself the extra time to double and triple check my meds, I have never forgotten that mistake and the lesson that I learned.
I hope you are able to find support, and forgiveness and stay in nursing, we need you.
Julie, I am so sorry for your pain, and for what happened. Listen, to what Bill Levinson is saying in his posts because it makes good sense. You are a good and loving person. The system failed you and your patient.
I have made mistakes too. Fortunately, I have not made one that resulted in a sentinal event. I did have a patient respond to a med (the wrong one) that I administered one time. Fortunately, the MD was present and ordered a reversal drug to help minimize the problem. The patient suffered no ill effects. Even though things turned out well for the patient and myself, I will never forget it. You learn from the mistakes.
You are right, things will not be the same again. You will check your meds and recheck your meds when you hang them.
In other words, the hospitals do not have anything that resembles the kind of quality systems we use in industry, where errors like this are pretty much impossible. (If they happen, they don't happen more than once because we fix the underlying root cause.)
Factories process thousands or even millions of "widgets," from multiple product families. Each requires different processes and process recipes. Widgets don't get the wrong processes (~ wrong meds, wrong operations) because we have traceability systems and production tracking systems.
We also have safety systems. As an example, it was possible to hang the wrong drug on an IV unit but it is not possible to connect a hydrogen line to an oxygen tank (or vice versa). The connections are designed to be incompatible because connecting oxygen to a line that contains hydrogen, or vice versa, can cause an explosion.
If you give me five malpractice cases, or five cases in which a nurse is "written up" for making a mistake, I can probably show in at least four cases why the hospital administrator(s) and not the doctor or nurse should be disciplined or even let go.
Thanks so much for the information. It always seems to come down to the nurse when any error is made, whether it is really the nurses fault or not.
What will it take for the medical equipment process to be made as mistake proof as possible? That these meds can appear alike and both be accessible from the same place, and both be able to be hooked up to an I.V. as though they were interchangeable meds is horrendous.
Yes, the nurse is supposed to read labels, but that is what a mistake is - you're in a hurry and make an error. The point of safety is that cardiac toxic meds should not be kept together with things like antibiotics, nor should they be able to be hung in the same manner.
There are two kind of nurses, those that have made a med error, and those that have YET to make one. If there is a nurse that has been in nursing any legnth of time and never made a mistake, well, I just woudn't believe it. Unfortunately, our profession's mistakes aren't just losing a bundle of money, or reshuffling paper work. Our's can be, and are fatal. When you got your license, it said you were qualified to begin practicing and grow within your profession. But guess what. Your license didn't say you were perfect, and never inferred you ever would be. If you were to quit, your patients and nursing would definetly lose out. But you will lose out even more. Keep doing what you love, you will only be better because of your mistake. Don't let it lead to an even bigger mistake.
quote: "when i mentioned your post to my daughter, saying how awful there don't seem to be any support groups, she checked it out, and came up with the following:
from the mitss website: "if you are a nurse who is having difficulty dealing with the emotional aftermath brought on by an adverse medical event, we urge you to give us a call at (508) 337-2900 or toll free at 888-36mitss. all contact will be kept strictly confidential. call us today and begin your journey of healing."
weetzie,
i'm glad your daughter looked that up and you shared it. i've never heard of it before. good to know it's there. if anyone has any personal knowledge of how helpful this support group is, please share it with us.
My hospital experience was in a small rural hospital and thankfully, we had a bulldog for a pharmacist. I used to get so tired of getting ridden all the time, but I'm glad that she was so anal (sp) about stuff. All our meds were flagged and set apart from ABT;s. Forgive yourself; if the pt did not die then already the outcome is great. I've made more errors that I can count, but usually everyone was really laid back about it unless it was a potentially "bad" error.. I found that If you are up front and honest with the staff, MD's, family, etc. that it carries you alot farther. What you are feeling is perfectly natural and we've all been there. Let's face it; there are some idiots who have absolutely no business with a license. these are the dangerous ones and usually are weeded out (hopefully) before too much harm is done. ( After 15 years, you don't sound like one of those nurses.) Quit beating yourself up for that only reduces your convidence level and that, for me, is the hardest part of nursing. The fact that you have a conscience tells me that you have a lot to offer the field of nursing, and we need as many good nurses as we can get. It's good that the MD's are supporting you; usually when push comes to shove, they will hang your @#$ out to dry. and probably will if this goes to court. Learn from your mistakes, get up and go to work. Take comfort in the fact you have a lot of "buddies" on this network in your corner X's & O's
I almost made a lethal error when I first started working in ICU... This was back in the 70's. The RN's would give respiratory treatments with NS. I reached for a vial of NS, was called away and put the bottle down. Upon my absence someone picked up a bottle of KCL which was in an identical multidose vial and put it down where my NS was. When I returned I picked up the KCL and drew of 5cc to put in the nebulizer. Fortunately for me I noticed the label in the nick of time. Now I am so cautious about labels.... I will never forget what almost happened.
hi my name is julie. i have been a nurse for 15 years and have loved almost every day. i can easily say it is my passion, however, less than a month ago, i made the first and only med error of my 15 year career. i hung a med that looked like pcn, but was not. it was a cardiac toxic drug and resulted in the almost immediate death of my beautiful pt, and the end of my life as ive known it. my spirit is broken, my ability to take the next breath, severely challenged. and the internal battle against the thoughts that are there to defeat and destroy me are constant.
i am feeling desperate to connect with anyone who has lived through this same horror. i have been trying in vain for over a week to find some way of linking up in a support group for nurses trying to get thru something like this. of the 310,000 med errors in this country last year, 7000 were fatal! where are all those nurses?!! are they all suffering alone like i am?
PLEASE, IF YOU HAVE BEEN THRU A SIMILAR SITUATION, CONTACT ME. I BELIEVE WE CAN HELP EACH OTHER SURVIVE IN A WAY OTHERS MAY NOT BE ABLE TO UNDERSTAND. i am outraged that a support network does not exist for these nurses even with documented sucides reported.
any suggestions? thank you and i am so sorry for the somber theme. julie
GOD BLESS YOU! YOU ARE IN MY THOUGHTS AND PRAYERS!
I'M VERY SORRY FOR WHAT YOU ARE GOING THROUGH.(((HUGS!!!!!!!)))
Any seasoned nurse who says that they never made a med error, no matter how small, is lying. Any nurse that thinks it can't happen to them is a fool. Hang in there. I have seen some almost potentially fatal mistakes made by some of the best nurses I know. That is one of the thiings that scares me the most about my job, the huge level of responsibility. I know that people in non-bedside nursing positions could never appreciate it. Before I was a nurse I was a HUC, NA, Home Health Office Staff, and of course, a student nurse. Still, nothing could have prepared me for the shock when I graduated and took on the responsibility of my own assignment. You are certainly not alone and I hope that you receive a lot of support by reaching out.
hi my name is julie. i have been a nurse for 15 years and have loved almost every day. i can easily say it is my passion, however, less than a month ago, i made the first and only med error of my 15 year career. i hung a med that looked like pcn, but was not. it was a cardiac toxic drug and resulted in the almost immediate death of my beautiful pt, and the end of my life as ive known it. my spirit is broken, my ability to take the next breath, severely challenged. and the internal battle against the thoughts that are there to defeat and destroy me are constant.
i am feeling desperate to connect with anyone who has lived through this same horror. i have been trying in vain for over a week to find some way of linking up in a support group for nurses trying to get thru something like this. of the 310,000 med errors in this country last year, 7000 were fatal! where are all those nurses?!! are they all suffering alone like i am?
PLEASE, IF YOU HAVE BEEN THRU A SIMILAR SITUATION, CONTACT ME. I BELIEVE WE CAN HELP EACH OTHER SURVIVE IN A WAY OTHERS MAY NOT BE ABLE TO UNDERSTAND. i am outraged that a support network does not exist for these nurses even with documented sucides reported.
any suggestions? thank you and i am so sorry for the somber theme. julie
hello
i am sorry for you and i understand you very much but don't worry because in our job these problem are natural the end you know HUMAN IS A PECCABLE .god is with you and you are examined by him now 0
Bill Levinson
1 Article; 69 Posts
In other words, the hospitals do not have anything that resembles the kind of quality systems we use in industry, where errors like this are pretty much impossible. (If they happen, they don't happen more than once because we fix the underlying root cause.)
Factories process thousands or even millions of "widgets," from multiple product families. Each requires different processes and process recipes. Widgets don't get the wrong processes (~ wrong meds, wrong operations) because we have traceability systems and production tracking systems.
We also have safety systems. As an example, it was possible to hang the wrong drug on an IV unit but it is not possible to connect a hydrogen line to an oxygen tank (or vice versa). The connections are designed to be incompatible because connecting oxygen to a line that contains hydrogen, or vice versa, can cause an explosion.
If you give me five malpractice cases, or five cases in which a nurse is "written up" for making a mistake, I can probably show in at least four cases why the hospital administrator(s) and not the doctor or nurse should be disciplined or even let go.