First Big Error - Advice Needed

8 hours ago, NewRNontheBlock21 said:

Hi, all! I'm in desperate need of advice. I'm a new grad fresh off orientation and I made my first major error. I had a diabetic patient who was NPO for a morning procedure, and I forgot to grab his morning blood sugar. Long story short -- the patient was hypoglycemic in the OR. Thank goodness he was unharmed (asymptomatic and conversational), but I know how easily the outcome could have been different. I've never forgotten to do something this important before, and I'm terrified what this means for my position on my unit. Obviously, this will be stuck in my mind forever, and I doubt I'll make this mistake again. I have a meeting with my manager next week, and I have no idea what to expect. If anyone's been in a similar position, I would appreciate hearing your experience. Thank you!

Take it from an OR nurse-not a big deal! Diabetic patients often have their sugars rechecked in the Pre-Anesthesia area and, depending on the length of the surgery, likely intraoperatively too.

Sending you peace and reassurance. All new grads ever make mistakes -- some that cause harm, most that do not. You are very high risk for errors right now, off orientation but still new. It gets better. As a new grad I accidentally hung D50 instead of NS for a diabetic patient's maintenance fluid. They were fine, but needed insulin correction. I can't remember if I was off orientation at that point, or at the tail end of it. I felt stupid and horrible, regardless. There is no way to become an experienced nurse without going through this. It's part of learning.

Be gentle to yourself.

10 hours ago, NewRNontheBlock21 said:

I had a diabetic patient who was NPO for a morning procedure, and I forgot to grab his morning blood sugar. Long story short -- the patient was hypoglycemic in the OR. Thank goodness he was unharmed (asymptomatic and conversational), but I know how easily the outcome could have been different.

Yes, and he could have been noted to be hypoglycemic during the procedure even if you had checked it when you regularly would have. That isn't to say that you shouldn't make note of this--you should. But don't catastrophize.

If the meeting with your manager is about this situation I strongly recommend that you do not go in there in a self-deprecating manner. That is how you teach people that you will accept being terrorized over the smallest matters. Just be pleasant and professional and listen to the feedback. Acknowledge the learning experience and say thank you for the discussion. The End.

I am not sure how not checking a blood sugar is considered a med error. As a previous poster said, a patient with diabetes will likely be checked in pre-, during, and post-procedure. And it can quickly be addressed by anesthesia. 

I was written up for an error of omission once: I had a patient who was going to the GI lab early (end of night shift) and was to have an antibiotic hung. He became confused and combative and refused to allow me to hang it, even with his spouse in the room. I notified the MD on call (this was before hospitalists) and he simply said he didn't know anything about this patient. So I called the nephrologist on call because this was a dialysis patient, and while I was on the phone the day shift nurse transported the patient to the GI lab. I was written up for not giving the antibiotic, even though I had documented the patient refusal and the call to the on-call. I was "counseled" about that particular GI doc being a real horse's behind and not to worry about it. 

What if you had remembered to check the sugar and the patient still became hypoglycemic? There is a reason diabetic patients have hypoglycemic protocols onboard: stable one minute, tanking the next. It’s not like you cut off the wrong leg in OR. The problem with a lot of healthcare workers is that they have become soooo unforgiving. Newt misses happen all the time and that’s so much better than an actual event. 

Hopefully, your meeting next week is with a manager who’s been there, done that and knows that mistakes are going to continue to happen even as we struggle and strive to be perfect in our delivery of patient care. Risk management probably wants to know what led up to this incident: change of shift admissions, patients calling for pain meds, somebody fell...in acute care, there are tons of distractions that can lead to simple mistakes. Follow up is the job of risk management.  
 

In my current role in primary care, I was reported for escorting a direct admit to the acute care unit to give a hand-off report instead of calling report. (I’m still fresh out of a 20+ year med-surg career when that happened). The doctor that I work for said (after I informed him of what happened), “ **** ‘em”! He’s speaking my language!? The floor new the patient was coming because the doctor had to speak to the accepting physician and had the room ready. At that moment, I knew this is where I planned to be until he retires. 
 

You’ll be OK. Our perception of the gravity of some mistakes is what keeps us from making the same ones again. But there will be others to take its place...believe that!

If your hypoglycemic patient was sent to the OR alert and talking, then he wasn't in serious trouble. If the procedure is any length, anesthesia draws labs and monitors results, same with the PACU.

At least you weren't like me who forgot about the npo after midnight for my diabetic patient and gave the NPH insulin and the patient became hypoglycemic. 

Thank you all for your kind comments! The issue is that I hadn't checked his 0600 sugar before he went, so he might have been hypoglycemic with me, or might not have been -- but no one can say for sure since I missed it. The OR RN submitted an RL on it, so that's why it was brought to my attention. My manager seemed unusually curt in the email she sent me, so that's only added to my dread. And thankfully I did check with the provider prior to giving his NPH/regular insulin! 

Sure it's not perfect that you missed a scheduled blood sugar check, but if your pt was alert and talking he was not symptomatically or dangerously hypoglycemic. Someone will have symptoms before they suddenly pass out from hypoglycemia, and I'm sure you would have noticed when talking to him. I'm sure you were busy; 0600 is a busy time on night shift.

Just review your process for keeping track of tasks and move on = ) It's easy to beat yourself up, and it shows you are conscientious and care about your patients and being a good nurse, but don't be too hard on yourself! We all make mistakes and it didn't harm the patient.