Feeling terrible about mistake

[Forever a New Nurse]

Hi

I'm writing today to get support/feedback and mostly to just express my sorrow to others who may understand what I have done. I am a registered nurse of 7 years; 5 years in ICU ( 2 years SICU, 3 years CCU). I feel constantly humbled by this job and as soon as I get semi comfortable I am again brought to my knees. I love doing patient care, but I hate dealing with lines and medications that can easily hurt or kill a patient and feel I am obsessively careful, and double triple check everything. I worry a lot about everything (which is why I have no place in the ICU in the first place) and am always questioning when I will make my exit from bedside due to this constant worry and anxiety when at work.

Here is my mistake I need to share: I had a very sick patient on balloon pump with swan. PA pressures were high, wedge high, pt is needing diuresis and cardiac support until more desirable fluid status is reached. B/p low with MAPs in 50's. Swan has no VIP port. Pt is on dopamine and dobutamine running to side port of swan. IVPB are running to PIV. Lasix drip going at 1ml/hr (5mg/hr) to other PIV. PIV with lasix not the best line, considering starting new line, but decided against it b\c pt has swan with many ports. I have never infused anything in the PA (yellow) port before, but honestly did not know you weren't supposed to. I debated whether to use yellow port (PA) or blue port (CVP) and connected the lasix to the yellow port d/t I was not drawing mixed venous gas and could still monitor the waveform while the med was infusing. I actually thought I made a good call, as the yellow port has 3ml saline flush that would help the 1ml/hr lasix trickle in. (I know, terrible terrible terrible call)

Day shift came in and I'm grateful it was an experienced nurse who immediately switched the lines and informed me of my error. I feel so dumb for not knowing this, as everyone else I've spoken to seems to know this is a huge 'no no.' Of course I am now obsessively reading articles on it and can't believe I made this error that could have easily hurt or killed this patient. I feel paralyzed by this mistake.

Luckily the patient was not harmed and only improved over my shift. It was actually a good shift up until the time I gave report and now I just feel terrible. Crying a lot, hard to get out of bed. Just thinking how the patient was thanking me, so grateful for my care when over the night I was infusing a med directly to her pulmonary artery! Luckily it was only lasix running at very low rate. Also lucky to have been followed by an experienced nurse.

I feel so embarrassed and bad for my actions. Will I ever feel experienced in this job? I feel I have to leave bedside care out of fear of making a mistake and becoming a non-functioning human after. Also, knowing that it's going to be a big PSN and I have to face the music that I was the one who did it. I want it to be brought up and blasted for everyone to hear, so no one else makes the same mistake. Though it seems no one else would, as I am the only one who seems to not have known about not infusing meds through the PA port. I feel embarrassed and humbled, it's going to be hard to show up again.

It doesn't matter how many times you double, triple check something if you don't know what you are doing is wrong. 5 years in the ICU working with swans and I did not know you are not supposed to infuse meds to the yellow port. WOW!.

Thanks for listening.

[Oldmahubbard]

I am not in your speciality but I am thinking of you.

[alaskaman]

Every clinician makes mistakes. It is impossible to know everything. You learned not to use the port. Lesson learned. Pt is ok. After 30 years I can tell you so many stories. Here's one. At the ICU VA Anesthesia established an epidural and used ported tubing. The patient had two central lines. The pt became unstable and I looked for the line to give neo gtt. Thought that I had the right tubing and rechecked. It went to the epidural. It would have killed him. Drilled a new rectum into the Anesthesiolgoist, but it has stayed with me. I made the error. I rechecked. I was milliseconds away from giving the neo.

So count your stars that nothing went wrong....and you LEARNED. Take a deep breath. It will not be the last one you take when working as a Nurse in ICU.

["nursy", RN]

Here's one for you...working nights at a teaching hospital, with interns and residents all learning by doing, meaning every line had multiple attempts before success. This night a resident was putting in a temp pacer and it took HOURS... he just wasn't getting in. Finally about 4 a.m. it's in. Resident goes to bed exhausted. It's up top me to clean up and put a dressing on. After putting the dressing on I noted that one little corner of the dressing looked a little raggedy, so I whipped out my scissors to trim that part of the dressing and make it neat. Well......guess what I just happened to cut besides the dressing...yeah...THE PACER WIRE!!!!! Talk about wanting a hole to open up in the middle of the floor and swallow me whole, RIGHT NOW. Anyways, I did survive, and here I am 38 years later.

One thing I did learn, ALWAYS trust your little voice...the one that niggles at you when your not 100% sure of something. Every time I ignored that niggle I paid for it. Nowadays it's even easier, you don't have to ask anyone and feel like they're judging you, you can pretty much look everything up.

[ptier_MNMurse, BSN, RN]

While I know you are feeling like your guts are up in your throat and you're totally on edge, and you don't want to face the issue, and you just feel shook up, just remember you are not the only one who has ever made a mistake. AND most people have made a mistake that makes them feel this way, so most people should be sympathetic toward this.

I once had been infusing amio for a patient and they changed the bag to high concentration, which I hadn't fully wrapped my head around as it was an unstable patient who was kind of circling the drain, and popped the new bag (high concentration) onto the old tubing (standard concentration). I then infused the entire bag in 6 hours (supposed to last for 24 hours). We stopped the infusion and luckily the guy didn't go into a block or anything, but it left me feeling awful.

I came to find out that there was at least one other person who had made this mistake and we had a debriefing session where we were able to find multiple holes in our system which lead to some systems changes. I still felt terrible, but it helped me to learn and grow and I can tell you I will never not check a concentration again on my meds!

As long as you grow from this and can give others support and encouragement down the line when they make a mistake, I think you can turn this experience a little more positive. We are all here to help each other grow. You don't know what you don't know. The longer I am in this profession, the more I realize how true that is. That's why I am never afraid to ask a "stupid question". I would much rather ask a "stupid question" and get a few tilted heads and furrowed brows than to cowboy up and make a mistake.

Now you know and won't do it again! Keep your head up! The fact that you feel this way is telling that you care a lot about what you do, and want to help people! Use this to make yourself a better nurse and continue to help your patients!

[Forever a New Nurse]

Thank you all for your responses, story sharing, and support ❤️

[alaskaman]

If you stand on the train tracks for a living, from time to time, you get hit by the train. Keep your chin up. You have courage, smarts and love to move you through this....

[Crystal-Wings, LVN]

On 5/3/2019 at 4:36 PM, alaskaman said:

If you stand on the train tracks for a living, from time to time, you get hit by the train. Keep your chin up. You have courage, smarts and love to move you through this....

This sounds very wise!

[LeMa88, BSN, MSN, RN]

I'd like to share to, my ADHF patient, came in, severely fluid overloaded.

Cardiologist saw her, prescribed Lasix infusion at 5mg/hr. The ampoules are 250mg in 25mls so I have that in a 30mls syginge. Checked, went to set it up, rechecked, programmed the infusion as 250mg in 250mls so the patient was having 50mg/hr instead of 5mg.

A few hours lately, attended to her hygiene, the pump started alarming. I looked, saw the syringe was almost empty, thought to myself " oh that was quick "- proceed to the drug room to make up another one.. then I stopped, I realised what happened, my heart dropped to my stomach, I broke down in cold sweat, I cannot believe what I had done. I went to check on the pt, turned off the pump, went to the I/C, told her what I had done. She said "is the patient OK?" "yes" "did you turn the pump off?" "yes" "take some blood to check her UEC and electrolytes"...

I also rang the registrar to let him know, all he said was "ah well, maybe she needed that" I was beside myself

[alaskaman]

Does your pump have a med library? If so it should have prevented this rapid infusion of lasix.