First med error/mistakes

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I feel like I need to get this off my chest in order to really be able to move past it. Anyway, I am about 4 weeks off of orientation as a new grad nurse. I work on a tele/cardiac unit. Last night I had the WORST shift of my life that really made me question whether I should continue in this career. I should preface this with the fact that I'm on night shift and had worked every other night for a week straight. I was burned out to say the least. Anyway, I started on the floor with 3 patients and 1 admission coming up from the ED. 1 of my patients was totally fine and didn't have many meds so I didn't have to worry about him too much. My other 2 patients were a handful. One of them was from a memory care unit, impulsive, combative, agitated, and yelled "HELP!" every 5 min (that is not an exaggeration), and on an Amnio drip. Other pts were complaining that it made them feel anxious and they couldn't sleep. My other pt was an elderly woman who was admitted for a previous cardiac arrest from another hospital. Her daughter (who is an experienced ICU nurse) was in the room overnight.

Within 30 min on shift, my dementia pt was already consuming most of my time. I had to sit in the room with him to chart because he kept calling out so much and the bed alarm went off every 5 sec. There was an order for a PRN 1:1 sitter but my charge nurse told me we should just wait to see how the shift goes before pulling a PCA off the floor to sit with him. Within a couple hours of being on shift the other nurses are telling me to call the Resident and see about getting him an order for Ativan, which I did but the Resident opted against it. I felt like I shouldn't have asked for a sitter because then everyone loses a PCA and the other nurses were trying to help manage the pt with me. Anyway, no sitter the whole night is what happened and instead we all ran in there every 5-10 min to manage him.

In the meantime, I have an admission from the ED coming up with a BS in the 40's, asymptomatic, and my elderly lady is going into fluid overload. Then her doppler results come back and she has DVT in one of her arms. So I rush to get a Heparin drip started and her daughter is asking me explain why so I have to call the MD to have him explain that they found a DVT. Heparin drip is hung, verified with a second RN. I had previously explained that the pt has DVT in her right arm. The pt also needs abx but only has one IV access so I need to start a new IV. The second RN gets me all the IV materials and finds a good vein for me which ends up being in her right AC. I don't even think twice about because the other RN has more experience than me and I figure it's ok to use that arm if she says it is (1st mistake). In goes the IV and I hang the antibiotics. Now this whole time my dementia pt is yelling, needs a new Amnio bag, and my admission is now waiting on pain meds. Everyone else was tied up so I had to figure out how to handle everything on my own. I couldn't find my charge nurse for hours.

My elderly woman's PTT comes back and I am on autopilot so I follow the protocol for Heparin drip rate change based on PTT....except I forget that this is her baseline PTT for the initiation of the drip and I don't need to do anything about it (2nd mistake) because this is only the second Heparin drip I've ever hung. A second RN comes in to sign off and verify the bolus and rate change with me. As I am giving the bolus the daughter states that it's her initial PTT and the dr didn't want her to have a bolus, which is true. We never gave her a bolus when I first initiated the drip. When the second RN came to verify the rate change she asked me if I was starting the drip and I said no because the drip had already been started so she assumed that this was just protocol as well. Miscommunication. Anyway, I call the dr to let her know I gave the pt a bolus by mistake (who said the bolus amount I gave her wouldn't really make a difference and it was ok), write up an incident report, and continue with trying to manage my other pts (meanwhile feeling guilty as hell the whole night).

Later the daughter calls me in to the room to assess the pt because she thinks she is getting more fluid overloaded. I assess the pt and agree so I call the dr for an order of Lasix. Lasix ordered, no problem. The end of my shift all hell breaks loose. Every pt needs a new bag change of either IV fluids, Amnio or otherwise. My Heparin pt's PTT comes back at >150 so I stop drip for an hour and then reduce rate. I triple verified that before restarting the rate with second RN. Then during shift change the day nurse and daughter notice the abx bag is still full and I know for a fact that I saw the pump say secondary infusing but apparently the clamp was still shut so it appears that I actually never infused the abx (3rd mistake?). Finally, I realized my new admission had an order for a 1:1 sitter as well and call to get it D/C'd because I wasn't given any indication of that in report and he has been fine since arriving on our unit. The Resident says he thinks the admitting dr still wants him on it and I have no freakin clue why! To top it all off my new admission has an order for a pain med he is allergic although I did verify with the Resident who said it was ok to give.

Overall, I feel like I just couldn't get my stuff together this shift and most of my mistakes happened with one patient. I honestly feel like I was burned out from having to work every other day for a week straight and then I had a pt whose acuity was just too much for me that night. On top of that my dementia pt was yelling and extremely rude and disrespectful to me the whole night. I know he has dementia but it still sucks being told "You need to come when I call you" OR "You're not moving fast enough otherwise I wouldn't have to yell Help so many times". I just wanted to curl up in a ball and die. I mean how many mistakes can one make?! And it's simple stuff that I just didn't think to ask about because I felt like if I keep asking questions I'll look even more incompetent. I should have just asked ALL the questions. Like the DVT in the arm. I only later had the thought to put a limb restriction band on the pt but that was AFTER we put in the IV. By the end of that week I should have called out or something because I was not able to think clearly. And I always have trouble with IV bags running out before I can switch them out. The thing that really blows me is that I set an alarm on my phone for when to change out the IV bags and they never went off when they were supposed to. I'm just so disappointed in myself and my lack of critical thinking skills. I'm also disappointed in that fact that I basically made sure that this ICU nurse knows I'm incompetent. I mean it was the absolute worst feeling of my life having to leave the floor and not being able to make eye contact with her. I don't know if I can handle this type of stuff anymore.

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Specializes in LTC, assisted living, med-surg, psych.

First of all...breathe.

It's going to be okay. The only kinds of nurses who make mistakes are those who have, and those who will. Yes, the heparin issue could have been a big problem, but it wasn't and you learned something from that.

Don't be so hard on yourself. You had the shift from Hell, and you dealt with it the best way you could. The only thing I would advise you is that next time you have a patient like the one who should have been a 1:1, you should be persistent with the powers that be when it comes to advocating for the patient and yourself. Don't take No for an answer the first time, or the second. You simply cannot be in more than one place at one time, and high-maintenance patients like yours need more supervision than you can give. What if he had fallen and split his head open on the way down? What if he'd ripped out his IV? Guess whose fault it would have been...well, you know the drill.

You're a brand-new nurse. You can't be expected to be proficient at this career for another year or two; unless you do something egregious or make a lot of them out of carelessness, mistakes usually don't get you fired or labeled incompetent. Just be sure to do things by the book while you're learning, and always ask questions even if you think they're stupid.

Good luck to you, and Welcome to Allnurses! Feel free to vent anytime, we're here to help.

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3 hours ago, Smhcdh0623 said:

There was an order for a PRN 1:1 sitter but my charge nurse told me we should just wait to see how the shift goes before pulling a PCA off the floor to sit with him. Within a couple hours of being on shift the other nurses are telling me to call the Resident and see about getting him an order for Ativan, which I did but the Resident opted against it. I felt like I shouldn't have asked for a sitter because then everyone loses a PCA and the other nurses were trying to help manage the pt with me.

You made it through.

Out of everything you said, there are just a couple of main things that could possibly have made a significant difference.

- Possibly your work schedule. "Every other night for a week straight" can mean a couple of different things, but neither one of them are great. Advocate for a workable schedule ASAP so you can feel well-rested and capable when you walk into work.

- I agree with @VivaLasViejas - don't take no for an answer regarding a sitter when a patient is monopolizing time in that way.

Your train of thought about not wanting to take a PCA off the floor/away from other nurses is a very common and completely erroneous line of thinking. This is as good a time as any for my lecture about accepting responsibility for what you can, and letting others accept responsibilities that lie with them - in this case, I'm referring to your employer. This is their business and they are billing patients for appropriate care. Your charge nurse's suggestion was fine - - for about the first 10 minutes. After that, the assessments have been made and the situation is clear - s/he can go ahead and arrange a sitter.

Should other RNs happen to resent this, that would be on them, and their beef would be directly with the employer. Don't comport yourself as if any of it has anything to do with you - don't feel sorry for it and don't accept blame for it. This was solely about this patient's needs and the staffing plans.

Learn what you can from this and you'll come out ahead. ?

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Specializes in Varied.

We all make mistakes. What is important is that you acknowledged your mistakes and now you can work on making them better. As a new nurse you will have many "problems" competing for your time and you need to be assertive when you need help (even if that is pulling one of the PCAs to sit so you can do your job).

Take a few breaths and look forward to the next day. I wish you the best of luck.

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I truly appreciate all of your advice and encouragement! I already know that when I go in for my next shift I am going to think of it as a fresh start. My unit director talked to me after my shift and told me 2 things that I will certainly take with me always. He said, "One, I don't want you to take this shift home with you. Leave it here. Today. Two, this does not change my perception of you at all. I still think you will/are a great nurse and will continue to grow."

I feel very lucky to have co-workers and a unit director that are so supportive. I am going to take this a learning experience. I will advocate for safety precautions to be put in place when needed, ask for more help when I feel overwhelmed, and ask questions even if I think they are stupid. Thanks again for your advice! It is much appreciated!

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You are a BRAND NEW NURSE!!

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You're a brand new nurse!!!

This sounds exactly like the unit I came from. I say "came" because I got out of there after a year and half (started there as a new grad myself). I had nights like the one you described every week (sometimes every shift I worked that week). I ended up leaving the bedside because the stress was destroying me mentally and I was basically told to suck it up.

Anyway, it sounds like whoever made your assignment wasn't being smart. It's not safe to give a brand new nurse newly off orientation the patient load you had.

I have to say, I feel triggered right now lol. I can't count how many times an IV blew at the most inconvenient time (i.e during med pass when my 4 patients had med lists as big as phone books), or I was in between tasks and I get a call about an abnormal lab value that I had to then pause what I was doing to get the fellow/attending on the line, or a patient was maxed out on every PRN pain med they had and were then demanding something stronger ("or I will speak to your manager!"). It's tough. But I promise if you stick with it you will learn how to time manage and prioritize.

Advice for the next crazy night:

1. lay eyes on the exact lab value/order in the chart with your second nurse (I suspect that perhaps you verbalized to the nurse what the PTT was instead of actually pulling up the value... perhaps then one of you would've noticed it was the first PTT and not the second)

2. always glance at your med bags/pumps each time you're in the room to keep tabs on when you'll need to change it

2a. set the VTBI as 10-20 ml less than the actual volume left to give you time to grab a new bag or reprogram the pump for a little more time if you're super slammed and need a few more minutes.

Hang in there. I PROMISE it gets easier.

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Specializes in Primary Care.

You will look back on this one day and realize that days like this happen to everyone. One bit of advice I might offer from my time as a new nurse... set your fluids to less than what will be infused so that they alarm as "complete" despite having 100ml left to infuse. Especially your maintenance fluids. This sounds silly but it works better than a cell phone alarm. Especially if your patient is alert or has family in the room. They will give you the "her iv pump is beeping" call and that will cue you to either get a new bag of fluid ready or call pharmacy for a new bag. Might help alleviate running out while waiting for the replacement bag to be hung. Keep your head up and do NOT ever be afraid to ask your peers for help. We are all in it together.

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First of all you made it through the night!!! Some shifts I just want to crawl into a ball haha.The problem with nurses we strive to offer the best patient care to our knowledge and ability, but soon come to realise that with staffing shortages and/or patient load just can't.

If workload is too high, always tell your nurse incharge and state reasons why and document in notes before getting caught up. It may not always change your shift, but you've put it on the record if anything happens and, if nothing can be done that night, improved staffing for the morning might be arranged.

You are one person, you can only do what you can do! I work methodically through my workload. Don't try to get distracted (easy said than done) especially when doing medications. I find when you get flusted it takes longer to do things, than if just make a plan of what's highest priority and work down the list. Assessment of patients and obs, medications, personal care (as best as possible in that order).

Like what was said previously, a standard infusion line takes about 20mls to prime, so then dialling up minus 20ml from the volume of fluids you are giving. Also with piggybacked IVs onto fluids put the volume of your maintenance fluids as 1mL, so when your infusion of IVABs is finished, it will beep without putting air in the line and is ready for you to flush. I tend to also put a timer on my heparin go off after 4hrs, but if you can't get to it quickly to just press continue, then I'd recommend not doing this.

Shifts like this, we all have to come to terms with the fact that we can't do everything and next shift will have to pick up what couldn't be done. It's a 24hr job after all! As long as you work safely and to the best of our ability. It gets easier with experience, but some shifts are just plain horrible.

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