Today I screwed up...

allnurses Guide · Feb 14, 2013

Ha! As a student, I once administered Sedatives to > 30 patients on an ortho ward -- at 9 AM!!! (didn't realize the significance of the green ink on the MAR - oldtimers will get this).

Hmm.

As I recall, green was the PM shift's color.

You mean you gave the 2100 meds at 0900?

That's a good one!

Esme12, ASN, BSN, RN · Feb 14, 2013

Long story short, today was my first day of second semester clinical (flu shot issues). My rotation is in an LTC facility and the patient I had used a rollater walker. Well, a classmate told us an instructor was doing a lesson (which wasn't true), so I finished my peri care and allowed my client to walk to her chair. She was at the foot of the bed, so I figured she was fine and went to go see what was going on. Well, little did I know, night shift had unlocked the wheels on her bed. Not even 15 seconds down the hall, she lost her footing, tried to settle herself on the bed, slipped, and fell. Thankfully she didn't hit her head, and wasn't hurt at all.
I feel so horrible though. My instructor ripped me a new one at first, but started going a bit softer once she learned all the facts. She did email the program coordinator though. I've never been "unsafe" before; this is a first time incident. Still, I've already had to fight with this school due to unfair treatment in my first semester. I fear I'm going to get it good. Of course, I am using this incident for my reflection due in two weeks...
I feel stupid. I feel horrible. And I really don't know what to think. All I know is my program coordinator or my instructor really can't make me feel worse than I already do. 15 seconds. That's all it's seemingly taken to put a black stain on my student record...

15 seconds....just 15 seconds is enough to cost someone their life. If this patient was on an anti-coagulant, fell, struck her head, and ended up with a head bleed......she could die. She could fall, fracture her hip, require surgery, develop a post op infection, or blood clot, or some other complication that would end her life.....simply because she fell. Yes.......Just 15 seconds CAN save.....or cost.....a life.

It is a big deal. Patient safety is a big deal. Never assume (ass-u-me) that someone else has done something. Count on no one but your self....because if you are the one on duty...it is your responsibility. Before you leave that patients bedside you have to be sure it is absolutely safe. Will patients still fall? Yes, unfortunately they probably will....the key is to do everything in your power to prevent it.

We all make mistakes. Admitting them and being truly sorry is another, owning them is another. The key is not repeating the same mistake over again.

I wish you the best on your nursing journey!!!!:)

Stephalump · Feb 14, 2013

Wow, what a rough day (for you and the patient!)

I know it's hard to be in the not so positive limelight, but all you can do is move forward as learn from it. You definitely aren't the first to make a mistake and you won't be the last.

This will probably be the very last time you fogey to make sure a bed is locked, though

We have all sorts of safety stuff drilled into our heads, but incidents like that are what take it from hypothetical lecture to real world habit.

I was so excited to put my first foley and NG tune in a patient, I ran out of the room celebrating instead of putting the side rail back up. If I puy it down i always remember to put it back up, but someone else did it that time and it didn't even occur to me.

Fortunately my instructor looked back into the room, but unfortunately my instructor looked back into the room. I paid for it, I'm still paying for it, and I'll probably keep paying for it until I change CIs, but the good news is I'm obsessed with checking side rails now :)

Stephalump · Feb 14, 2013

Ha! As a student, I once administered Sedatives to > 30 patients on an ortho ward -- at 9 AM!!! (didn't realize the significance of the green ink on the MAR - oldtimers will get this). I do recall that my instructor had to take a couple of days off afterward. Filling out that many med errors took hours. Probably the only reason I wasn't booted or at least suspended ... the chief resident came to my defense and said that they hadn't had such a relaxing day in a long time... maybe they should give sedatives in the morning at least once a week. And I not only survived, but probably became the most careful med-giver in my entire class.
I know it was a horrible experience for you - but someday, you will be sharing it with another newbie to help him put things in perspective also. We all make mistakes. The important thing is to learn from them. That's how you become an expert.

Best. Story. Ever.

nurseprnRN, BSN, RN · Feb 14, 2013

Ha! As a student, I once administered Sedatives to > 30 patients on an ortho ward -- at 9 AM!!! (didn't realize the significance of the green ink on the MAR - oldtimers will get this). I do recall that my instructor had to take a couple of days off afterward. Filling out that many med errors took hours. Probably the only reason I wasn't booted or at least suspended ... the chief resident came to my defense and said that they hadn't had such a relaxing day in a long time... maybe they should give sedatives in the morning at least once a week. And I not only survived, but probably became the most careful med-giver in my entire class.
I know it was a horrible experience for you - but someday, you will be sharing it with another newbie to help him put things in perspective also. We all make mistakes. The important thing is to learn from them. That's how you become an expert.

Oh, I so love this!! (I used green ink for years)