How could I do this?! Forgot to give report.

[Ioreth, BSN, RN]

This is the sort of thing that I have nightmares about, but have never done, until now. 

I've been a nurse for a 1 1/2 years, all on the same unit. Worked 1 year on nights, then switched to days. I had the usual rocky moments as a new nurse, but nothing really serious. I'm generally conscientious and careful.

Today I started with 5 patients, which is a heavy load on this unit due to the kind of surgeries we have. I discharged one in the early afternoon. 3 others were pretty needy and one was particularly medically complicated in a way we don't usually see on this unit. My 5th patient was ready to go home, had absolutely no need to stay there. Already independent and minimal pain needs. I just did peeks in when I was running past her room and she was doing fine. I messaged the PA for her surgeon and he said that he would write discharge orders when he had a chance. I got everything set for discharge and waited, but no order.

When night shift came in, I gave report on my 2 more complicated patients to one nurse. The other two remaining patients were to go to another nurse, who was new to our unit and getting checked off for competencies. We got sidetracked on something or another with these checkoffs and somehow I mixed up in my own head that I had already handed off one of my other patients to her, but that I had handed off to the other nurse. So thinking that I handed off two patients each to two nurses, I got on the shuttle bus.

Once I got in my car I realized that I hadn't handed off my easy patient! I think because I had prepared her discharge and was just waiting on the go order from the PA, I had slotted her in the "Discharged" part of my brain. I immediately called in and gave report over the phone. Thank God it had only been about 10 minutes. The nurse was very gracious about it and laughed it off. Fortunately this nurse had the patient the night before, so it really was only an update.

I just feel like an idiot. I was proud of myself for walking out on time, everything done, even with those care-heavy patients. No wonder I was on time! I wasn't even done. I have NEVER done anything like this before. Ugh.

[Iheartwoundcare, MSN, APRN, NP]

Oh you poor dear. I can feel the anxiety through my screen. ?

I have had nightmares about this type of thing as well. And also that I didn’t give meds to a patient all day.... 

I say quit beating yourself up. It was a hectic day. You did exactly what you should have done and called the oncoming nurse. I will say in the future maybe you could check off each patient in your notes so that you know each one was reported off. I’m a HUGE list maker and “checker off-er”- I’ve always been paranoid like that. Also- why didn’t the oncoming nurse realize she still needed report on a patient? 

Just breathe. And don’t dream about this tonight! ?

[JKL33]

No biggie. And you handled it correctly. ??

My nightmare is going to give report and realizing I haven't seen the patients, not checked them even once, since I got report on them at the start of shift. Now that would be bad.

All's well with you; take care.

Oh, PS - don't be making a big deal about this when you go back to work. Just carry on.

[Sour Lemon]

I once had a patient that I forgot about until after 1AM. Her roommate had been my my patient the night before and was recently discharged. So when I looked in the room, I saw a dirty room and thought "She's gone."

When I finally found a moment to sit down and chart, I realized that I was missing someone and I was horrified. I went back to the room and looked on the other side of the divider curtain and my patient was sleeping very peacefully. I gave her 21:00 meds at about 01:30. Thank goodness she was stable, because I did not so much as LOOK at her for over six hours. Her vital signs were taken by a CNA two times. Thank goodness the CNA was paying attention.

Anyway, hope that makes you feel better. I don't think I've ever forgotten to give report, but I have had nurses leave without giving report to me. It wasn't a huge deal. One never realized it and never called. I still managed to figure things out.

 

[Nunya, BSN]

Been there, done that.  You'll never do it again. As long as the next nurse just laughed it off and you DID eventually give report it's fine.  Every once in awhile your brain takes a vacay and stuff like this happens, it's life.

[JBMmom, MSN, NP]

I had one nurse on orientation forget to give me report three times! The first two times we reached her by phone and I think I was pretty accommodating. By the third time I told her I was going to have to follow up with her preceptor- who had also left them floor without checking that I got report.

These things happen, as you said it turned out to be no big deal. You won't do that again.

I remember when I was first trained for charge, I had a dream that I forgot to assign a patient for day shift. When I came back that night they told me no one was ever assigned to that patient and they died! I awoke in a panic and after that I made sure I double counted all the patients with assigned nurses every day.

You did a good job, you had a busy shift, and no harm was done. Don't stress about it.

[Ioreth, BSN, RN]

All was good this morning when I came in. I ended up discharging that patient immediately after handoff this morning. The night charge has always been a mentor to me and share some funny handoffs-gone-wrong stories. We had a giggle and that was that. Will NEVER do it again.

Weird thing is I do have a system to make sure I'm done. I have one of those folding clipboards and I keep a separate sheet for each patient, which I keep until they discharge. I just write my notes for each day in a different color. When I'm done with report, I go through them and stack them in room order behind the unused sheets. This time I just went "yup that patient discharged too" and tossed the sheet in the shred bin. Now I'll do that while checking against the bed board.

[DavidFR, BSN, MSN, RN]

Chill! It's OK, nobody died.

We've all done something like this.

I was one moved to another floor (oncology breast surgery) after having taken handover on my regular floor (medical oncology) since they were hectic and both an RN and a care assistant hadn't turned in.

Hence I had two handovers swirling round in my head, was on an unfamiliar unit where I couldn't find anything, the place was hectic and on top of all  that, despite having some surgical experience I'm totally medically orientated and don't usually work in surgical areas, so I was a tad disorientated to start with.

Come the morning (day staff already arrived) my colleague and I realise that he thought I had room 34 and I thought he had room 34. No  care assistant on the shift hence 2 ladies not seen all night!! I fly in quickly to check breasts and redivacs. Fortunaly two very stable, day 2 or 3 post-ops, not in pain, vitals OK, and thankfully NO regular night time meds. They'd both slept solidly all night and hadn't missed me. 

I was horrified so I know how you feel, but it was all shrugged off since no harm done.

On the other side I have also discovered a patient in a room who I didn't know was there. No handover, thought the room was empty. Again, patient OK so I laughed about it with the offending day nurse in the morning. She too, felt dreadful.

That we feel bad about it at the time shows we have a conscience, which is good. It shows you're a good nurse. Error is human and we all do silly things sometimes. At a distance you will laugh about this - believe me!!

[JKL33]

11 hours ago, DavidFR said:

That we feel bad about it at the time shows we have a conscience, which is good. It shows you're a good nurse. Error is human and we all do silly things sometimes. At a distance you will laugh about this - believe me!!

Agree.

It's good to realize that something hasn't gone ideally, recognize our part in it and seek to make a change. In terms of human emotion, yes we might feel "bad."

As an offshoot to that idea, though, I do think that even though we might not feel great about what happened, we should not expect to be treated poorly (punished, written up, talked to, etc., etc.) for situations like what is described in the OP and similar. I believe that to carry ourselves in that way is to invite petty criticism that over time (a very short time) is traumatizing and inappropriate.

[CrunchRN, ADN, RN]

That seems like "chump change" compared to all the things that can and do go wrong!

[speedynurse, ADN, BSN, RN, EMT-P]

We have all made mistakes, whether as a new nurse or experienced nurse. In this busy, chaotic world, it can be exhausting to be a nurse. You are human and will make errors. It sounds like you are very conscientious and made a mistake and then corrected it. It happens!

[amoLucia]

Congratulations on your new membership to the "Did I REALLLY Do That Stupid Thing?" club!

I'd bet we're all members!! I know I was a member back when ...