First Major Mistake, Patient Didn't Get Blood, I'm Afraid

[ICURNVUS]

I am a registered nurse that has always worked intensive care. I recently took a job on a Nephrology unit at a large Medical facility in my area. This morning I received a call from the clinical nurse manager asking questions about a patient receiving a blood transfusion in hemodialysis. And yesterday I worked day shift and I normally a night shift nurse. When I initially took report the patient in question was already in hemodialysis. The off-going nurse let me know that no nurse nor the ICU Rover nurse was able to obtain blood from the patient nor get IV access on the patient. The nurse sent down orders for the dialysis nurses to obtain a blood sample on the patient and she told me that hopefully the patient would be there long enough to also receive the blood in the hemodialysis unit before coming back to the floor. I had six patients two going to procedures two going to procedure the following day having to obtain consent right site forms blood consents etcetera. One discharge, on admission from cath lab.This patient arrives back from dialysis and in report the nurse did not make mention that the patient received blood in the hemodialysis unit nor did she mention the Hgb result from that morning,she told me that she pulled off 2.8 kg they were trying to pull off 3 kgs but the patients blood pressure dropped to 80 over 70 and she also mentioned that the patient was a little groggy because she had just had pain medicine which I found out later was not correct she had had the pain medicine at 7:54 a.m. that morning and that just wasn't true. So anyway patient came back I assessed her she was alert and oriented pretty much but just in a great deal of pain her husband asked what her hemoglobin was so I told him that I would need to go and check so I had to pull the patient over and I looked in at 7:44 a.m. that morning the patient's hemoglobin was 6.4. So I went back in the patient's room and she told me that she got two units of blood downstairs in hemodialysis and her husband wanted to know what what was her hemoglobin since she got the blood in hemodialysis. The patient was alert and oriented so I went and that is when I realized that's why they didn't get the blood that morning because she was a very hard stick , no IV etc. So our orders say that we get a hemoglobin 4 hours after blood is administered so she came back around 12 so I said between 4 and 5 I would have taken another sample got very busy throughout the day . I saw in her orders it was saying for her to have blood transfused 2 units also saying that blood product was ready but the time at which it was entered in the computer was so much earlier in the day while she was in dialysis I was going off of what the patient told me and what the previous nurse said and the fact that she had no iv access and it was reported to Hemo that the floor was unable to obtain either.I guess Long story short I found out this morning that the patient did not get blood in hemodialysis and was having to be sent down to hemodialysis this morning just to have blood transfused. I am absolutely mortified I feel defeated and this is the first time that I have had what I consider a major medical mistake that I've made. I know that I should have called hemo about the blood being given in Dialysis.back to verify that the patient received blood but I did not I went off of what the patient since she was alert and oriented and had been receiving dialysis for years. That in addition to the nurses report that morning and the fact that the patient had no IV access I made a very wrong assumption and it caused the patient to have an unnecessary procedure in hemodialysis this morning. I'm worried about my job now and I just don't know what to do as I wait for the influx of calls from hospital admin today. ?

[JacobIloved, BSN]

Is this actually a major mistake? There was an error in communication and the patient didn't receive blood, but nothing happened to the patient, right? I would definitely call up the manager and ask to talk about what happened, and maybe offer solutions to avoid having these types of communication mistakes happen again. Will you get fired for it? Probably not.

I've been in your situation before, where I've made a major mistake (a patient coded). It was a stupid mistake, a moment that anyone could look at and give me a duh face over. I got the dreaded call from admin, but I wasn't fired. I was given the opportunity to look at and overhaul protocols/policies/procedures and teach my fellow nurses on what not to do.

So don't beat yourself up over it - the patient didn't die, and actually sounds pretty asymptomatic except for some grogginess. The goal is to learn from the mistakes you make and build your practice to prevent errors.

[guest83140]

Six patients seem like a lot with the high acuity of them in that unit. You should have a "performance improvement team" that would trace the steps in what happened and put in quality controls that would prevent future errors or omissions. It's not about you trying to make a mistake but a mistake was made due to unforeseen circumstances of communication and instructions. We all have made mistakes, some went unnoticed or was fixed quickly. In my past day and night shift hospital work, being in charge, I heard of many mistakes and to call physicians to try to correct them. That was back in the 1990s to the early 2000s days. Back then, you could get a couple of medication errors in your file and was written up but it didn't go to the board or anything. It was a personnel matter. I think it stayed for your duration of employment and was cleared out after seven years. Now, I think it depends upon your value to the unit and your relationships with important people. If they want to throw you under the bus they could if they didn't like you. I have seen it go both ways. Managers want to keep their jobs and fear family reporting everyone. I think if the problem can be solved on your own and corrected quickly, it's way more of a positive outcome. But if you have evidence of an omitted report, as your notes or witnesses, this truly helps the situation. A long time ago, an evening shift nurse left a DNR dead and when I made rounds around 11:30 a.m. after getting a charge report and report from the leaving nurse. I went to patient B who was stiff in an 70 degree angle. The family complained that the funeral home had to take measures to correct him for the casket. My manager wanted to write me up but I told her that this patient had to be dead for at least 2 or more hours for his whole body to stiffen. So they wrote her up and changed reporting outside of each patient's room. Something may need to be changed.

[Nurse SMS, MSN, RN]

I have never worked anywhere that allowed a hemodialysis patient to get blood outside of dialysis due to the huge risk of fluid overload. I am, frankly, surprised they would expect you to give blood on a dialysis patient.

[brownbook]

Your situation is such a FUBAR I can't follow what happened.

You are not solely responsible for the error. Write down the facts of what happened. Try to make it a short concise list.

Ideally administration, with your helpful insight, will not blame anyone. Instead put safe guards in place so it doesn't happen again.