First big nursing mistake....need some support

rn undisclosed name · Aug 5, 2010

Unfortunately, any nurse with some experience has made a mistake. Believe me, I'm sure people aren't really talking all that much about it. Unless you're a nurse who continually makes mistakes, well, then those are the nurses that are really being talked about. Try not to beat yourself up over this and like others have said it'll just cause you to be a little more careful.

I'm sure there was some amount of blood loss with the surgery and there was no harm done. That is really great that you have that much support from your co-workers and manager.

ADPIE10 · Aug 5, 2010

My impression is that you are admitting to committing a mistake and taking accountability, at a personal basis this is an important for all nurses. Additionally, it is unlikely that you will make this mistake again. If it were to occur again by you, then it would be obvious that you would be considered unsafe to practice.

From a managerial perspective, a multiple root cause analysis should be performed. From the analysis, it is likely that new processes and procedures would be identified to decrease the incident of the same error occurring again in the future. It is important for management to distinguish the difference between unsafe procedures and unsafe nurses. Whenever an incident occurs, it's rare that a single event was the sole contributing factor of an error.

Use this as a learning experience, perhaps this error hasn't been committed by some of us, but some error will undoubtedly be committed by all us.

Ruby Vee, BSN · Aug 5, 2010

oh, goodness! i've seen people hang blood on the wrong patient and i thought that's where you were going with this. that would have been a big nursing mistake. yours was just sort of average. it was the right blood, wasn't it? the right patient? no harm done? and you learned from it? i'm thinking that you're never going to make that mistake again. you will, however, make some other mistake one day. everyone does. we're all human, and i don't know any perfect people.

i'm thinking that you've done a lot more things right than you did wrong. you were cognizant of the possibility of making a mistake, and you read over that order several times to ensure that you didn't. as soon as you realized that you made a mistake, you admitted it and set about to make things right. you called the doctor and gave her a chance to assess the situation and see if more orders needed to be given. you took full responsibility for your actions without blaming someone else, lying about the situation or trying to cover things up. and you realize the enormity of your error -- in fact, you probably feel a whole lot worse than you need to.

welcome to the club!

given that there are no perfect people and everyone makes mistakes, the only people who say they don't make mistakes are either liars or too stupid to realize they've made one. you're not in either of those groups. you did exactly the right things, and i'd let you take care of my mother, cover my patients or work next to me any time.

VivaRN · Aug 5, 2010

As others have said, everyone makes mistakes. Anyone with experience (who is not in denial) knows this.

Even more than the mistake itself, the wise folks will watch you for how you handled the mistake. It's not the event itself - it's how you manage it.

A bad way to handle a mistake is to lie, blame or try to cover it up. A good way is doing exactly what you did.

Take a deep breath. Remember that each day is a new day. The emotions you are feeling will fade with time and you will have a good story to share when you are the experienced nurse.

P_RN, ADN, RN · Aug 5, 2010

You made a mistake, you admitted it, it was reported, you learned a hard lesson and you got great support from management.Now put on your reeboks and go to work, and always remember you are a good Nurse and you are human like the rest of (us all of us) who have also made mistakes.

P_RN (Just another Human Nurse)

military spouse · Aug 5, 2010

:redbeathe

I have been an RN now for 10 months. I work on a med/surg floor in a large hospital and I love my job. Just got my yearly evaluation literally 2 days ago and it was great. Our DON said I was doing a great job and had talked to some of the nurses who had nothing but good things to say. Well last night I think I made everyone eat their words....I had a patient come back from surgery. Taped to the front of the chart was a blood slip that was filled out for 2 units of blood and signed by an RN. So the first thing I thought was that a nurse in PACU filled that out for me because this patient was to receive blood and it was a reminder to pick up the blood. So I flipped through the chart to find the order written from the doctor. I found one that said T&C 2 units PRBC the day of surgery. I know that T&C means type and cross but when I read that somehow I was thinking "transfuse." I read the order at least 3 times because I told myself I was always going to be very careful as to not make any mistakes. Somehow each time I read it I thought in my head that it meant to transfuse 2 units PRBC. I dont know if it was the blood slip that was filled out on the front of the chart that just automatically made me think I needed to give blood or what. But I looked in the computer to see if the blood was ready which it said it was and I went and picked up a unit and hung it. It was still running when night shift came on, I gave report to the night shift nurse and sat down to chart. About a half hour later the nurse that took over this patient approached me and asked me where I had gotten the order to transfuse the blood. I started to say that I found it on the chart under the orders but as soon as I started to say that I realized my mistake. The nurse said "it just says type and cross." I immediately felt like i was going to throw up. I kept saying oh my gosh i cant believe i did that, i cant believe it. I am so sorry. Luckily that nurse is wonderful and has taken me under her wing from day one and she sat down with me as I bawled my eyes out and hugged me and said whats done is done and we all make mistakes. just learn from this and dont let it happen again. she filled out an incident report and called the doctor who she said was not angry, just said that she had not ordered the blood to be transfused. today i received a call from the charge nurse who said that our DON wanted her to call me and let me know that the doctor was ok with what happened and that i shouldnt be afraid to come back to work. i am afraid to come back to work though, i feel like everyone is talking about me. i was so close to everyone and am well liked and thought i gained everyone's respect by turning out to be a competent nurse. (I worked on this floor for 5 years as a nurse's aide before i became an RN.) Now I feel like people are going to be keeping a closer eye on me and not quite trusting me anymore. I could just use some support and help getting through this because I feel extremely bad about it. Thanks

:redbeathe I'm so sorry you made that mistake, but EVERYONE makes mistakes. It sounds like you work with a caring and professional group of co-workers and it was handled both appropriately and professionally . Stop crying!! You sound like a great nurse and I bet you NEVER do that again. Even the Doc wasn't angry. Stop beating yourself up.:hug:

msjellybean · Aug 5, 2010

no Biggie, I had my ICU RN coworker make the same error. Turned out the blood did the pt good and it never went further than an incident report. No one thinks less of her. Now I know of another error where someone hung a heparin drip instead of 250cc saline with blood..hmm.Thats a real one.

That kinda reminds me of a patient that was transferred to our floor. The floor she came from transfused 1 unit of packed cells through her fluids at the time. Which were D51/2NS with 20 of K. Yikes. And the nurse that did this has been around for a while.

Kyrshamarks, BSN, RN · Aug 5, 2010

Ok...YOU SCREWED UP...now that it has been said get back to work. EVERYONE makes mistakes. After making one you need to step up to the plate and bat agian. The patient is fine (and I will bet that she actually is better for getting the blood), the doc is not mad, the DON is not mad. Then that leaves only you mad. Why be mad at yourself for an honest mistake. You will learn form this and you will get over it.,

BluegrassRN · Aug 5, 2010

Why do you need our support for this?

All these threads about how "Nurses eat their young" and "Nursing is a toxic environment full of b*tches". Your coworkers sound *wonderful*. Your fellow nurses, charge nurses, and DON are reassuring you that mistakes happen, learn from them and move on. They went out of their way to reassure you, calling you at *home* to do so, and you are still worried about what people think?

It's chilling, I agree, to make a major mistake. And this was one. Any nurse who has been practicing for a while has done so, too. Whether they know it or not. I've done it. You are in a career where your errors affect humans directly, and at the worst can kill someone. While we all know that unconsciously, when the reality of it smacks you in the fact, it's scary. It sounds like you've gotten great advice and support from your coworkers. Why is that not enough?

KSU-SN · Aug 5, 2010

thank you everyone for the advice and kind words. I am feeling better, moving on, and taking it as a lesson learned. Still dreading going in to work tomorrow because I am embarrassed but I love my coworkers and hopefully they will not think any less of me. You're right, the nurse that took over for me last night was very supportive and tried so hard to make me feel better. And the fact that our nursing manager had me called at home to tell me that the Dr. was OK with it and to not be scared to come back to work meant a lot to me too.

Also, yes a second RN always checks the blood but the only thing we didnt look at was the order. We checked patient name, date of birth, med rec number, blood type, expiration date, lot number. I mean it was the right blood for the right patient, it was just supposed to be held for her in case she needed it.

Redhead28 · Aug 6, 2010

Everyone makes mistakes. Easy for me to say, but I know how it feels when you are the one that makes it. No harm was done to the patient by receiving the blood. I doubt that you will ever repeat this mistake again. It shows that you have empathy, integrity and ethics that you feel bad about this mistake. If you did not you would shrug your shoulders and sweep it under the rug.

Try not to worry too much. Again I say "try" because I know you will, I have and I would guess most of the nurses on this board have been in your position.

clemmm78, RN · Aug 6, 2010

oh dear. The stories we all could tell you about our worst mistake. Over 20 years later, I still remember my worst mistake and it could have turned out for the absolute worst if I hadn't caught it when I did. Mortified doesn't begin to describe how I felt about it. But I had to remember that it wasn't about me, it was about dealing with the problem that I had created and ensuring the patient didn't come out harmed - or worse.

You can bet what is most important to you that I never, ever came close to making that mistake. I still feel the horror that I felt then when I think about it. I also use it as a good teaching tool, because it happened in an ICU when it was dead quiet. The biggest mistakes, I've found, is when it is quiet. I learned never to let my guard down.

Hang in there. You're very fortunate to have that work support. And, remember when one day, an inexperienced nurse makes an error and you're there to help him or her. It will happen and you'll know just how to handle it.