First big nursing mistake....need some support

[KSU-SN]

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

[rn/writer, RN]

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.

I know one person who won't think any less of you--the other RN who checked the blood with you who also forgot to look at the actual order.

Seriously, it's okay to be a little embarrassed (the sting of that emotion will inscribe this error on your memory so you'll never commit it again), but if you're feeling mortified, then it starts being about your pride (in a not-so-healthy way). That kind of preoccupation can rob you of the concentration you need to move forward.

No one is above making mistakes. We just all hope to goodness that the outcomes don't hurt us or our patients too much and that we don't repeat ourselves. Thank those who have been supportive (it's obvious from your account that you are well liked and cared about) and file this under "Bullets, Dodged." Then get your head back in the game and take care of business.

[carolmaccas66, BSN, RN]

Thank you for being so honest when posting this.

This highlights something I have been complaining about for years and years and years - ABBREVIATIONS SHOULD NOT BE USED FOR ANY PROCEDURE! Especially things like blood transfusions. Too many mistakes happen this way. Different abbreviations are used in different hospitals as well that is why this practice should be outlawed. Although from what I can gather you got mixed up because you were tired/busy/whatever, isn't it your hospital's policy to always triple check any orders to do with blood? Also two nurses are supposed to hang this at the bedside, and check it all again. Maybe do this in the future.

Some hospitals I have worked out outlawed any abb's as they are too dangerous.

I never go by abbreviations - if unsure I always check with a senior nurse and the Dr. I know people use abb's cos it saves time, but when mistakes happen, time is wasted and lives can be ruined,

Complain to your facility as well that abb's should be outlawed for any procedure.

One case I remember was a nurse who though SOB meant sitting the patient out of bed. Well it stood for shortness of breath, and she dragged this poor patient out of bed who could hardly breathe & got into trouble for it. Not life threatening I suppose but it could have been if it was something more serious.

And no none of us are perfect, despite what some older nurses and managers say to you (and no I'm not targeting all older nurses, just the ones who forget that they too made mistakes when younger).

[Kooky Korky, BSN, RN]

Perhaps the doc should have ordered type and hold, not type and cross.

Forgive yourself and keep on going. At least your pt was fine and bosses are supportive. Keep going forward.

[rn/writer, RN]

Perhaps the doc should have ordered type and hold, not type and cross.

Forgive yourself and keep on going. At least your pt was fine and bosses are supportive. Keep going forward.

Um, "type and cross-(match)" refers to a process that, except in emergencies, needs to be done for the safety of the patient. Changing that to "type and hold" leaves out a valuable step.

The order to "type and cross-match" implies that blood will be gotten ready and made available. Such an order is given tens of thousands of times every day with the understanding that it is really an order to prepare blood, not an order to transfuse it.

The OP gets it, and has owned her mistake.