First day without preceptor and first error

Published

Specializes in Adult Acute Care Medicine.

Well today was my first shift alone, offically just me as the RN.:uhoh21:

I prayed to whole way to work. Oh, I was so nervous.

I took a 5 minute break to eat half a sandwich but was running the rest of the nght....PCA's, TPN, pain meds, new admit, etc....

Okay, by the end of the night I think things are pretty good...I actually got all of my work done and charting was almost complete. I was only there 10 minutes late....

So the night nurse who just came on comes up to me and says..."Is there any reason you didnt hang the rest of the potassium"?

"WHAT?", I am thinking...I am so very thorough as I am terrified of making a mistake.

The MAR showed 40 mEQs due. The day nurse had charted a time it was given. I did not know that it came in 10 mEQ bags and that I was supposed to hang another THREE bags!!!:o

I told the nurse that I had no experiencce w/ this (had only given PO before) and did not realize that I was supposed to hang more.

Although pt is fine. I feel SO bad, so stupid. On top of it, on my way out I heard the nurse tell another nurse about my error. I am not sure how I could have caught this w/out a preceptor right there. Now I am even more nervous about tomorrow!!!

I can't believe this happened on my first night on my own! I mean, I double and triple check everything! Tonight I even called a MD cuz she wrote "tab" for a medication and I wanted to clarify it was PO (a coworker said not needed, but I wanted the "correct" order).

Sorry to go on and on.

I would SO appreciate some words of encouragement, or similar tales of unintended med errors.

Up Vote Up Vote ×
Specializes in High Risk In Patient OB/GYN.

I have no wise words or sage wisdom, but remember-crap happens. And I'm sure you learned from your mistake-now you know to check into it, and if anyone on your shift gets K+ orders, I bet they get each and every bag right on time!

Don't beat yourself up, really. Not one nurse has avoided a med error. if s/he says s/he has, they're eitehr lying or ignorant to the fact.

Up Vote Up Vote ×

Don't be so hard on yourself, I would have done the same thing. About the K+, the other nurse should have written that she only gave 10 meq. If someone signs off next to 40 meq on a MAR they are saying that they gave the entire 40. How were you supposed to know how much was already given, what if she had given 20 meq instead of 10? It would be safer to have the dose listed at 10 meq with 4 different times that need to be signed off on.

Up Vote Up Vote ×
Specializes in Nephrology, Cardiology, ER, ICU.

I agree that if the MAR is signed off, how would you know to give three more bags??? And...then how would you know which bag was hanging?? First, second, third or fourth???

Seems like your hospital needs to get it together to make this easier. If I came to your floor as an agency nurse and the K+ was marked off, heck I wouldn't give anymore either!

Up Vote Up Vote ×
Specializes in ER, ICU, Infusion, peds, informatics.
i agree that if the mar is signed off, how would you know to give three more bags??? and...then how would you know which bag was hanging?? first, second, third or fourth???

seems like your hospital needs to get it together to make this easier. if i came to your floor as an agency nurse and the k+ was marked off, heck i wouldn't give anymore either!

i agree.

in some facilities, it is policy that kcl only gets hung in increments of 10 meq at a time. this is the standard i learned when i was in school, and was adheared to in all the hospitals i was at as a student.

then i moved half way accross the country, to learn that kcl is hung in increments of 20 or 40 meq at at time (depending on the ordered amt), and the rate reduced so that it is given at 10 meq/hr.

i guess you didn't give much iv kcl as a student or while in oreintation?

i think you need to look at how the kcl is handeled in your facility. when you write up the incident report, or respond to the incident report that another nurse writes, you need to make a point that 40 meq had been ordered, and it wasn't clear to you that it hadn't all been given.

(yes, an incident report needs to be written -- if not by the nurse that discovered the error, then by you. this is at least partially a "system error," and pharmacy needs to make the documentation on the mar more clear.)

it is one thing to be on top of these kinds of things when you have a limited number of patients. and while i acknowledge that kcl is a very important drug to be on-top of, it is difficult to catch all of the details when you have a whole slew of patients to care for.

as far as i'm concerned, better to err on the side of giving too little kcl than to give too much of it.

Up Vote Up Vote ×
Specializes in Float.

Yep what weebaby said.... 4 bags should have 4 times AND this should have been communicated in report "pt is getting 40mEq of K. I hung the first bag but there is still 3 bags to go" or SOMETHING.

Up Vote Up Vote ×

"as far as i'm concerned, better to err on the side of giving too little kcl than to give too much of it. "

i agree. someone with low potassium is less likely to die from it. many people go on for a long time with a low potassium. but a high one, they can die in minutes.

don't beat yourself. you have to remember that even if you do check everything twice or three time, that in a hospital setting mistakes will happen. mistakes shouldn't be looked at as bad. mistakes are a way of learning. from now on you are going to be very aware of meds given. that is a good thing. because with out this happening you won't have noticed how something could of been missed. i know you must feel really bad about the nurse telling another nurse. espeically if she was your preceptor. that wasn't right of her to do while you were still there. but is also a learning experience for the other nurses. who to your face may act like "how could you miss that "" but in reality it has given them a lesson learned.

it's good to know other mistakes from other co-workers b/c you will learn from them too.

here is one i will never forget. it happened to a co-worker. in our crazy med/surg floor i worked in, we would get tons of admissions, post-ops and blood transf. alot of copd pt who would be very sob. it was so common that our protocol was to call resp. therapy. also lots of people with asthma. well, one day lets call her nurse: a. she has this pt with sob. she called rt and pt received therapy. she did ok but still was having difficulties. so she called the rt again and the rt told nurse a that to give it some time and the med will kick in. an hour later the pt still felt she was short of breath. so they increased her oxygen. she felt better for a while. finally the pt fell asleep. what a relief to this new grad. the rt felt that it was normal b/c the pt had just came out of a hip surgery. well next day or so i can't hoenestly remember but the pt died. now you can just imagine what nurse a must of felt like. it turned out that the pt was having a pe (pulmonary embolism). as nurses we know what this is but in reality as a new grad and having such a commom sob in the floor for months, no one thought it could of been pe. now this is a huge lesson to learn b/c from now on when ever i have had a sob i make sure to check for symptoms of pe. look them up. is the best way to learn. good luck

Up Vote Up Vote ×
Specializes in Trauma ICU, MICU/SICU.

I agree with everyone else. NOT your fault. I am an advocate for owning your mistakes, but in this case I believe the system (the MAR lumping the 40 together when it is given 10 at a time), and the off-going RN who didn't tell you that she hung 10 out of 40. How did the nurse coming on know that the nurse before you only hung 10? Did she find 3 bags lying around and just deduce that pt. only got 10? Because if that is the case, that is a SCARY method of keeping track of potassium, a potentially lethal substance.

Up Vote Up Vote ×
Specializes in Trauma ICU, MICU/SICU.

WeeBaby,

That boxer puppy is adorable!

Up Vote Up Vote ×
Specializes in ED.

When we had one time orders, they were put on the back of the MAR one at a time so we could see that there would have been more than one bag to give. Plus we put a note on the front that there were one time orders on the back so it wasn't forgotten.

It happens I think to all of us at one point or another. Just a learning experience. Next time, if there was an order similar to that like potassium bags or blood to hang, just ask during report if all was given or not. That way you know. And its always a good idea to look over the previous shifts orders (like chart checks) and take a look at what is hanging on the IV pole (what antibiotics are up there, have they been given cause sometimes people like me forget to unclamp the tubing):icon_hug:

Up Vote Up Vote ×
Specializes in Travel Nursing, ICU, tele, etc.

OK that most definitely is a system error and not yours. Or it is the nurses fault who signed that she gave 40 meq when she did not. Let's see if she has the balls to stand up and own it!

I would SOOOO not feel bad about this, but I would be very concerned if you are somehow blamed or shamed for this error. You REALLY need to stand up for yourself on this one if things start going bad. Actually this will be a very good test to see how much integrity and honest reporting your facility exhibits in these matters.

Honest to God, I want to congratulate you on an awesome first shift!!! You ROCKED!!! Unfortunately in nursing you won't hear a whole lot of the good stuff you are doing, just the bad, so you need to give yourself the acknowledgement when you deserve it and you DEFINITELY DO!!

Just let it go.....don't worry about the other nurses talking about it. If they have any sense, they will see how easily it happened and perhaps be an advocate for you and for the system changing. You will learn A LOT about the facility and the people you work with through this experience!!! Keep us updated!!!

Up Vote Up Vote ×

Aww, give yourself a break. You're new. Next time you'll know better. I'm sure you'll learn something new everyday, and I'm certain all of those more expereinced nurses didn't get that way overnight. Pat yourself on the back for only making one error on your first night without your preceptor. :flowersfo

Up Vote Up Vote ×
+ Join the Discussion