Feeling terrible, first med error... (long)

[Bluekal]

Hello guys,

I just need to vent a little here. I'm feeling pretty bad right now and like I should have known better. First a little background. If you guys look at my previous posts. I was having pretty bad anxiety and stress in my first job. Now something good happened at around 7 months. Everything started to click and things made sense. My anxiety before work was gone and I was feeling comfortable in my role as an RN.

I constantly got praise from my patients and co-workers. I was learning a lot, and felt pretty good about working in the unit. Of course I felt stressed on some situations, but generally I was able to handle it and do a good job. I was happy again and sure that I was a good nurse, a green nurse, but a good nurse. I just recently completed my one year last week and was extremely happy about it.

Now something happened last night that shook my foundation and sent me back to square, my first med error. The situation was, a patient had decadron ordered. It looked like a basic order. Decadron XXmg q6h. Then at the bottom of the electronic mar there was a comment that said after 48 hours decrease to q12h, then after 24 hours to xmg BID for 24 hours, then DC.

(this is not an excuse for my mistake) Doctors never write instructions like that on our EMAR, they usually just DC the med and reorder the lower dose. I saw that in the EMAR there was scheduled doses for q6h for the next two days. I assumed that since my patient was a fresh transfer my doses would be day 1. I was wrong.

The next day, the night nurse also noticed the same situation and did some research to find out that the patient had been getting the original dose for two weeks starting at the other unit. The patient should have been off the decadron a week ago. Now looking back, I know that I should have looked back on the EMAR to see how many doses the patient had been getting. The thing is, we never get med orders like those. People at work tell me it's just a mistake, to learn from it, and not to worry because I'm in the middle of a long chain of nurses, pharmacists and doctors who dropped the ball.

I still don't feel better. I feel like I failed my patient. I thought I was a very thorough nurse and was starting to feel strong and confident. Now... I don't know.

Thank you for reading, I just wanted to let it of my chest.

[LynnLRN]

It does not appear that you caused the patient any harm with this mistake. I sometimes look at mistakes as good things because it makes you more careful in the future. I bet you will never again just assume that you are giving the first dose in the future. Just learn from this experience and be more careful in the future and be thankful that no serious harm was done to the patient. No one is perfect.

[KelRN215, BSN, RN]

As others have probably told you, this wasn't YOUR mistake. It was a mistake that you didn't catch but if the patient was supposed to have been off the decadron weeks ago, many other people didn't catch it either.

IMO, that's not a good way to order a decadron taper. I work in Neurology/Neurosurgery and we have issues all.the.time with decadron tapers because we have residents who rotate in for 3 months and our computer system is not the most user-friendly system. Usually I get orders for decadron that go something like this "decadron 4 mg q 6 hr x 4 doses, decadron 3 mg q 6 hr x 4 doses, decadron 2 mg q 6 hr x 4 doses, decadron 1 mg q 6 hr x 4 doses, decadron 1 mg q 12 hr x 2 doses, decadron 1 mg q 24 hr x 1 dose." It's a correct taper but the problem is, the residents don't often go through and change the "start dates" for all of these doses so the computer defaults to start them all the hour after the order is written and it pops up on the computer with every.single.dose being due at the same time. It's a big old mess to go through and switch it too. In this sense, eMARs leave a lot more room for error than paper MARs did. HOWEVER, at least in our system if they write the number of doses, the order for 4mg q 6 hr automatically dc's itself after 4 doses have been given.

I agree that this is something to learn from. Maybe your pharmacy and informatics team can design a better way to enter orders for medication tapers or maybe the rotating MDs just need more education on the system you use and the best way to enter orders.

[merlee]

NOT YOUR FAULT !!!! Take some deep breaths and move on, if you can.

[nurseprnRN, BSN, RN]

be part of the solution. offer to work with the pharmacy, the pharmacy committee, the it folks, and the risk manager to fix this (these orders aren't only written for dexamethasone-- they are common for all kids of steroid tapers, and others).

[Dempather, RN]

::sigh::

Five years into nursing and I found that we have plenty things to blame ourselves for (i.e.: our OWN mistakes, how we respond to certain things, etc) and we work hard to control how often they happen and how we can do better next time (often I find this comes from just slowing down and thinking about what I'm doing -- which can be difficult when the time we're allotted is just enough for us to work on auto-pilot... no questions, just do do do !)

However, somewhere along the way, we've decided to carry the burden of feeling responsible for the mistakes of everybody else. I understand where you're coming from... you missed seeing that the patient should have been tapered off Decadron. But, in all honesty, where in the heck was the person who wrote the order? I'm going to try to keep in check here, but did the MD/NP/PA decide to write the order and then take three weeks off?? If a day went by, ok. But a week? As important as it is to write an order for a medication, isn't it just as important to follow-up with these things? We're held accountable for the things we ask others to do, right? Delegation, delegation they tell us!! And if we don't, we feel bad. But look, if somebody else doesn't, we feel bad, also!

Right, right... so it got through the MD, and got through the Pharmacy, and got through you... and you feel the guiltiest because you were supposed to be that final checkpoint (I used to be a soccer goalie and felt plain awful when somebody scored on me until I realized it passed by every other person on the field, as well). This, by the way, doesn't make mistakes acceptable-- I'm not saying that. But they happen, and we're human. Healthcare is a team sport (bear with the corniness)... and just like soccer, I'm coming around to learning this myself now (I still write posts for support ). I've been in your spot, and I'm sorry it happened to you, and the patient, and the whole crew but you can't carry all that responsibility.

BUT, you can learn from the error, try not to drag yourself down about it too long, and do better next time. I thought the post that mentioned to "Be part of the solution" is very helpful. Having a clinical educator on the floor was something else I've learned can make a big difference.

Make yourself better so you can avoid this, and maybe catch it for somebody else. We do the best we can with what we have and what we know. I read this over and I feel like I sound like a ramblin' woman. Ohh well...

[Bluekal]

Thank you all for the encouragement. I will use this mistake as a learning opportunity and make sure it never happens again. I will make sure I'm part of the solution. I am aware that decadron and steroids need to be tapered, and our process generally works fine. However, this time the doctor was new and wrote the orders differently.

The other neurosurgeons just write multiple orders like 4mg decadron q12h for 48 hours. Then that order is Dc'd and a new one is placed such as 4mg decadron q12h for 48 hours and so on. That was what I was used to. Unfortunately, pharmacy missed the comments and did not schedule the other doses. They just kept the original going for two weeks. The doctors who followed the patient did not catch it as well. Finally, nurses for an entire week did not catch it either. (no an excuse).

I'm feeling much better, and as I mentioned, I'll take it as a learning opportunity. I just don't know what the consequences will be when I go back to work.