Guilt over other nurse's med error

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Prayers to you.

also a noc newbie,

Motivator

Check out your Employee Assistance Program for free, confidential counseling.

EXCELLENT advice.

Give yourself a pat on the back for catching the error. That's the important thing, and that your pt is okay.

Consider this your wake up call to be even more vigilant.

Catching this error shows us all how important it is to really check everything on our patients when we come on duty.

This happened to me not to long ago as well. I let my float nurse hang an IV med and she programmed the pump wrong.

Our job demands close attention to detail.

Now that you've learned an important lesson and had your wake up call strive to learn more and be a better nurse each and every day.

Nursing is teamwork

yesterday there was a huge med error made on my unit. i didn't make the error; in fact i was the person who caught it. my patient almost died during my shift. i had last night off, so i don't even know if the patient did die after all.

i feel so sick. i haven't been able to sleep. i'm terrified of going to work. i feel almost as if i had made the error. i keep reliving the moment when i checked the iv pump and realized that it had been programmed incorrectly. i just keep thinking that it could just as easily have been me who made an error like that. have i always been as vigilant as a could be? have there been times when i merely glanced at the pump settings during a double check?

i am shaking so badly that i don't know if i can work. also, i do not want to be grilled for information on what happened by my co-workers, although i really need someone to talk to. i tried to tell my family what happened, but they really can't comprehend the situation well enough to understand my distress.

i really like the nurse who made the error, and i am frightened for what will happen to her. on the other hand i am also resentful of her (and of the other two nurses who were supposed to have double-checked the med) for throwing me into the mess i had to deal with last night. i had to watch the patient's wife crying at the bedside. i kept thinking, "i hope she doesn't think it was me who did this to her husband." but then i also thought that i am absolutly capable of making a similar mistake, so why shouldn't she think it was me. haven't i just been lucky?

why do i feel so horrible???

good for you catching the mistake.this is called reflection and,"there ,but for the grace of god go i"! it is all to easy to let your mind slip and go on automatic pilot when you are doing things.this is a lesson to be ever vigilant and concentrate even though you know the procedure backwards.

Always think of mistakes as learning. You know what mistake was made, just be vigilant now not to do the same. You are new and scared and it is normal.

I agree with the advice from the above posters too.

(((HUGS))).

I can understand how you feel, a similar situation happened to me a few years ago. I realize you feel horrible but the patient must come first and what ever happens you did the right thing. The patient coming close to dying is not to be taken lightly and I'm sure it is hard for all involved as to what to do. You have nothing to feel guilty about and yes we can always make a mistake, but that is why we double checked and maybe they used the wrong calculation. My incident involved finding a bag of heparin infusing at 10 x the rate when I came on one morning. The nurse though she put it on 8/hr versus puting it on 80/hr. It was already on for 3 hours. It had to be reported right away and the lady ended up dying 3 weeks later due to hematomas on her spinal cord. The thing I've learned from this is to always triple check my gtts and to check them often. The nurse was older and ended up quitting nursing, they gave her that option. She was 2 years from retirement and worked nights which I'm sure played a factor. They let her go quietly and she got to keep her pension but I did feel sorry for her but this was serious and yes could happen to anyone.

My incident involved finding a bag of heparin infusing at 10 x the rate when I came on one morning. The nurse though she put it on 8/hr versus puting it on 80/hr. It was already on for 3 hours. It had to be reported right away and the lady ended up dying 3 weeks later due to hematomas on her spinal cord.

My situation was very similar to that, except that the medication had been running for longer. The concentration of the bag was entered incorrectly into the pump. Were the spinal cord hematomas in your patient directly attributed to the heparin overdose? Also--how long until a heparin overdosed patient is out of the woods?

My situation was very similar to that, except that the medication had been running for longer. The concentration of the bag was entered incorrectly into the pump. Were the spinal cord hematomas in your patient directly attributed to the heparin overdose? Also--how long until a heparin overdosed patient is out of the woods?

In theory until the coags come back ok, but in reality, if there's been bleeding in the interim, until that resolves, as bleeding out isn't so much the issue at that point as what the old blood does while it's there.

you were better/smarter than i,......working agency...came on duty found a patient with heparin running, knew what it supposed to be ......(units per hour) thought the ml/hr looked off.....didnt STOP right there to check it out.....the previous nurse had mis entered the wt...#s intead of kilos.....so he was getting 120 % more than he was supposed to......did "catch" it about 3 hours into shift......was wondering why that PTT wasnt coming down.......patient was fine......good luck

this is just so sad on different levels.

it reminds me that we nurses are just as vulnerable as our pts.

that the ability to invoke harm makes us as susceptible to our pts who can and will be harmed.

it's truly horrifying, when that reality permeates our cores.

op, i think that's what you are experiencing right now.

that it could be any one of us, either as the giver or the receiver.

go to eap.

prayers for your pt.

leslie

My situation was very similar to that, except that the medication had been running for longer. The concentration of the bag was entered incorrectly into the pump. Were the spinal cord hematomas in your patient directly attributed to the heparin overdose? Also--how long until a heparin overdosed patient is out of the woods?

The woman was found to have heparin induced thrombocytopenia(hit) before she was admitted but never relayed this to her doctor. We only found out a cdouple days later from her daughter that she had hit, which made things so much worse. The hospital kept it quiet from the family and I felt more guilty over that then getting the nurse fired. I onlu took care of her that first day before I went on a vacation and when I came back I heard she was in our icu with the hematomas. She died three weeks later. I would not even be able to guess to tell you how long would it take to be out of the woods with heparin reactions.

Usually heparin is running at between 10 and 30 ml/hr, depending on the weight of the pt and the concentration of the solution, plus their individual physiological response. If I saw 80 ml/hr I would KNOW something was wrong!!!

This is a good reminder to us all to double check our critical drips when we come on. To the OP, good catch!

I like the new pumps where you can program in the particular med, and it gives both units/hour and ml/hr, plus the name of the med.