Nursing 20 years/MED ERROR

Nurses General Nursing

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It was a bad day, on top of my plantar fasciitis, being in charge, people calling in like usual on a Sunday Morning (though never held responsible), I had a 12 hour shift in front of me. I took Vital signs for the Nurses to help out, I also carried a load of 5 patients. We had 3 admissions on our small ENT floor immediately in the morning. At the end of shift, when we are bombarded with admission and their dismissals from PACU and ER, There was an epidural line that was near empty. I could have ignored it but I wanted to be the 'good' nurse that doesn't leave empty IV bags etc for the next shift. I got my code from Pharmacy as the new bag was being sent. It took a long time. It got crazy when it arrived from the Tube system (same one all day),using the code I got from the pharmacist. I put it in my pocket, asked each of the three nurses to double check it with me, they were scrambling and couldn't find time. I was scrambling to accept 2 new patients myself to the floor. I ached, I hurt, I could hardly walk. The clear lexite box the med was in was covered with tape residue and you could not visualize what was in it. The lock was supposed to be locked by protocol and it was held shut by a rubber band. She had been on our floor for a few days. I went and got the key out of Pixis and was interrupted 3 x by others needing help and a family member in the room. I remember looking at the bag.. and I remember nothing. I don't even recall the label. I hooked it up, set the pump, locked it and walked away. I had put up Heparin. a sentinal event. It did not harm her, but she had no pain relief. I got a call the next morning at 5 a.m. from a nurse who found it. Everyone was absolutely in a panic and frantic. I don't blame them. I was in shock. I broke protocol.

I admitted everything. I did not attempt to hide it or skirt around it. I was honest. But in thinking about it I wanted to help the hospital from this ever happening again.

1. The lexite box was not openly visible to contents. (I was told it was my responsibilty to clean the box off to ensure contents were visible) Secondly, the box was never locked according to protocol for 3 days. (Probably to assist in visualizing contents.) The anesthesia nurse did not even check the box.

2. I did not follow protocol, 2 person check was not done.

3. Pharmacist gave the same code to everyone that day for tube system, resulting in a chance for a med error, which happened.

4. Nurses were too busy to assist each other, staffing inadequate.

5. Interruptions

6. Continued practice of admitting patients to the floor during/before report time causes extreme disruption and broken reports. 6:30 -7:30 am and the same, PM.

In the meeting in the next 2 days, where the event was discussed with my $56/mo Union present, I was offered resignation. I also had my name blackballed from the other hospitals for 6 months. I was labeled and unemployed. In shock, I sat in my office getting denials and turndowns continually. I had been previously nominated for awards twice for being a wonderful nurse. This mistake took me down. I understand 3 other nurses were let go in the process and one pharmacist. Because of me.

I had a mental health professional call me to discuss it. I was angry at myself and angry at the system. The patient was failed by me. I was failed by me, the hospital, my coworkers. I beat myself up. Gained 70 pounds. I lost a lot in this; good pay, seniority, friends, respect. It was a very rough time.

In two months I found employment and it was slower, way slower, and I had time to review events. I never stopped saying it was my own fault. I gained 70 pounds.

I met another fellow nurse from another state, similar event. He was given an option to take a med course through the hospital to correct and educate. He was very thankful this was offered to him and he totally understood where I was coming from. He said I did the right thing: I was honest. Because of this; I never lost my license but they did threaten to do so. The process is to be examined, not to punish anyone but to see where the errors were made and enforce how to prevent. People make mistakes. My problem is I know what was right, what was to be done correctly and I put my coworkers ahead of patient safety.

Now they have scanners for medications. A totally different process on epidurals. But those of us involved are gone. I know I learned my lesson. It still haunts me 10 years later.

Specializes in PCCN.

Your reasons 4 5 and 6 , are what's wrong, and I mean WRONG with nursing.

The suits don't care about this. It doesn't affect them when an error is inevitably made. It affects the licensee, so what do they care.

I'm so sorry this is affecting you this many years out.

This is THE MAIN REASON I am pursuing other non nursing means of employment. The money is NOT worth it; the potential for error is toooo strong.

Specializes in Clinical Research, Outpt Women's Health.

You made a mistake that was also the mistake of several others and and definitely poor staffing and unrealistic work load were big factors. And then the employer threw everybody under the bus. That is a problem in nursing for sure.

You need to let it go though. You endured and overcame and the patient was not harmed. You are a strong person and you deserve to have this gone from your life.

"The process is to be examined, not to punish anyone but to see where the errors were made and enforce how to prevent. People make mistakes"

This is true. You were not treated well at all, and for that I am sorry. It sounds like you've definitely learned from your mistake and took accountability for it.

Wow. Hard to even start typing as this sort of story is devastating on so many accounts. Nurses in acute care face this sort of chaos every day and it's not right. I'll just stop before I go off on an epic rant, and say this instead:

Please...don't let the 100% wrong and UNETHICAL way this was handled continue to affect how you feel about yourself, personally OR professionally. The aftermath of your error sounds positively EVIL. Those who abused and scapegoated you have a far bigger problem in life than you have, I guarantee it.

It can be really difficult to separate ourselves and view ourselves differently from the wrong that others have done to us, but that is my wish for you...that you would lay this "wrong" aside, realize it doesn't define you, it really has nothing to do with you. It is only a result of the evil of others. You already took all the blame you needed to take, years ago.

Thanks for sharing your story. Blessings to you...

Wow and I can see how that would occur and hope you are not still beating yourself up over it. Serves to remind me one of the reasons I quit working in hospitals where they just bombard the nurses with admits/transfers/DCs all day at such a pace it does not allow for 'slowing down' sufficiently and management throws nurses' under the bus 7 days a week and twice on Sundays (as was the case with you.) That and they will never concede that staffing makes a difference...it rather reminds me of a book title 'And the Band Played on,' (alluding to the band playing on while the Titanic sank.) I'm glad your license was not marred.

So often there are many failures that lead to events like this. However the nurse is the one who is ultimately responsible. It's an impossible job some days. Being short staffed puts the patient and the staff at risk - not just for errors, but injuries as well.

Specializes in Registered Nurse.

This is a really sad post. Thanks for having the courage to post. I suspect there are more cases like this that are not reported or ever discussed. I just don't understand how this is ONLY the nurses's fault. Why are individual's held accountable for responsibility that SHOULD be shared with the hospitals or medical facilities that short staff or fail to provide safe working conditions, adequate training, and clear policies and procedures that make nursing practice safe.

Some of the places I have worked review, polish and push safe work conditions just before inspections. I suspect the inspectors are putting up a show because i seldom see changes once the inspection is over. Minor details are reviewed and action plans created for improvements that seldom amount to anything more than a slap in the hand to the health care facility or institution. Meanwhile, individuals are held accountable for what may very well be a problem with the whole facility or system.

Specializes in Med/Surge, Psych, LTC, Home Health.

Wow...

Your post was hard to read, because I've made mistakes as well,

horrible mistakes, that still haunt me as well. I've made some whoppers,

sometimes not even under as stressful conditions as what you describe.

We just need to forgive ourselves, realize we aren't perfect, and move on.

It's hard though.

Specializes in orthopedic/trauma, Informatics, diabetes.

I disagree with poster that said 4, 5, and 6 are wrong. They are the number 1, 2, 3 for mistakes. People do stuff they don't normally do because they are set up to fail

We have a Just Culture where there is no blame. All the red flags for something to go wrong are there. It is no one's fault and everyone's fault. Why does it always have to be the nurse????

This is exactly what is wrong with the system. They expect people to report mistakes which were only caught by the nurse who made them and near misses when their only intent is to throw the nurse under the bus when it happens. Any nurse who thinks the hospital will have her/his back or accept any responsibility in that it may be the process is naive.

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