First big nursing mistake....need some support

Nurses General Nursing

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Specializes in Med/Surg.

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

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Specializes in Hospice, LTC, Rehab, Home Health.

I will say to you what my charge nurse said to me after my first "big mistake". I would be worried about you if you didn't feel like you do; but that you are feeling this way shows me that you will never make this kind of mistake again. You will always remember what happened -- not the patient's name necessarily but the circumstances will be just as clear 20 years from now as they are today. You will make other mistakes and you will learn from them too, but you will not make the same mistakes over and over and that's what will make you a great nurse!

Take care of you and be kind to yourself!:hug:

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Just don't beat yourself up about it in front of anyone you work with. They'll beat you up plenty themselves without any help.

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Specializes in Medicine.

Just wondering, don't you need another nurse to witness and co-sign the blood with you? (to catch the mistake with you?)

Everyone makes mistakes, you'll learn from this and become an even better nurse. No one is perfect and it really would not have mattered who made the mistake, people will still talk! Hang in there, be positive and I wish you luck in overcoming this (and you will!)

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Specializes in ER, Trauma.

FLArn says it all, except that if mistakes were against the law we'd all be in jail.

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Specializes in Med/Surg, Orthopedic.

Always, Always ask questions if you are not sure. Reading an order is so vague at times. Depends on the way it is written, if it is legible??, how receptive your mind is ( are you at the end of your shift or how busy you are). Thank God your patient did not have a reaction. But yes usually you do need to have another nurse co-sign/check the blood the you, unless it is an autologous transfsuion from TKR.

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Specializes in ICU-CCRN, CVICU, SRNA.

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.:eek:

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Specializes in Critical Care, Nsg QA.
I will say to you what my charge nurse said to me after my first "big mistake". I would be worried about you if you didn't feel like you do; but that you are feeling this way shows me that you will never make this kind of mistake again. You will always remember what happened -- not the patient's name necessarily but the circumstances will be just as clear 20 years from now as they are today. You will make other mistakes and you will learn from them too, but you will not make the same mistakes over and over and that's what will make you a great nurse!

Take care of you and be kind to yourself!:hug:

I believe I had the same kindness from my charge nurse when I had a big mistake. I agree that I'd be more worried if this just fell off your back and you were not affected. We all make mistakes, big, small, and everything in between. It's up to you to pick yourself up and go forward. You are still a good nurse!

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Specializes in ED,Psych, PICU, ICU,Neuro.

I'm glad you made that mistake now, early in your career, especially since there wasn't a bad outcome to the patient. You needed to know that you don't walk on water, that you're just like the rest of us - imperfect. Now the best thing you can do for yourself and your patients is to come back to work with a willingness to question. Pay attention to what your hearing your inner voice say. Why was it asking you to reread the order several times ? Next time you hear it turn to a coworker and ask her/him how they interpret the order. Nursing is a collaborative practise.

And please do not bore your coworkers with repeated apologies for your mistake. Believe me, we all have made mistakes. Learn from it and move on. This is another step in your maturation as a nurse.:redbeathe

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Specializes in PACU, OR.

Nobody's gonna beat you up, honey-if they try, just send 'em to ME!

And no-one's gonna talk about you behind your back either-they're too busy worrying about the mistakes THEY made, or the things THEY forgot to do, or the people THEY p****d off during the course of the day.

Your seniors sound wise enough to realize that you are an excellent nurse and will not hold a silly mistake like that against you; they probably know that mistakes serve one useful purpose, and that is to make us better people.

You remind me of a child who was in school with my daughter. She used to cry if she wasn't top of the class. Please don't stress yourself out because you're not perfect. Perfect beings do not reside on this planet!

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you sound like a lovely woman, and am very glad to hear you work in such a supportive environment.

and yes, it's good that you feel badly.:)

i think maybe you're right, in that others may be keeping an eye on you...

BUT, it'll be because they're being protective of you, and NOT because they think you're incompetent.

as others have said, you will remember this forever, so take comfort in knowing this will never happen again.

it's all good, honey.

you're in a good place with good people.

keep on shining.

leslie

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Specializes in Med/Surg.

I agree that you should try not to feel too badly about this although your concern shows how much you value patient safety. The patient however doesn't sound like they were in any way harmed from this.

The incident report is not to say you did anything wrong, it is to say that the process failed. They institute processes to keep us from making mistakes, when a mistake is made it is usually not one persons fault but a long list of mistakes that lead to the eventual error.

For example, in our hospital, we have to order the blood in the computer system for blood bank to release it to us, then we have to verify it with blood bank, we then have to verify the order, consent and blood with another nurse. Even if you didn't catch the mistake somewhere someone should have, that is why there are double checks on low volume high risk meds/procedures.

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