I almost made a stupid nursing mistake and now I can't stop thinking and analyzing the situation. HELP please?
I'm a first year nurse ( been a nurse for 10 months) and have started my new job one month ago. Today I made the dumbest mistake a nurse, or anyone could make. I drew up the wrong dose of insulin into a non-insulin syringe, (it was suppose to be given as IV PUSH). I drew up 0.4mL and ridiculously thought it was 4 units, when it is 40 units.
I DID NOT GIVE IT. I asked another nurse to look at the insulin for four units and I asked in public, and she says "I DON'T SEE IT". The charge nurse and another nurse were right there, and she then told me that the dose I had was 40 units, not four! The three nurses around me just stared with their mouths open, probably wondering what the hell is wrong with me.
I felt myself turn beat red in embarrassment I felt my ears were pounding. I did not give the medication, but the fact I made such a stupid mistake was ridiculous. She showed me the correct way to draw up insulin. I had given insulin before correctly many times.
NOW i cannot relax. I've done well on the unit and worked hard, and now everyone knows what a crazy mistake I almost made.
I'm new and I wanted to look competant, because I dont believe I am not. I just feel this moment definately left a mark, a humiliating one. I'm glad I had enough sense to ask another nurse for verification.
I'm so paranoid right now, I feel like others will think I'm a terrible nurse or just stupid.
Am i worrying too much? I have a habit of worrying what people think of me a lot, and I'm pretty sure they all think the worst right now.
Any advice, from any nurse who's been in a situation similar is much appreciated?
Don't believe for a minute that nurses around you haven't had similar "near misses" or worse. That's all it was. Not to belittle the issue by any means.
You sound like a great, conscientious nurse. Don't loose sight of that.
And, I don't think it's a bad thing to "not completely relax" when performing your nursing duties. To be complacent in our daily tasks is not a luxury afforded in nursing...
In our hospital, ALL insulin is double-checked as a high alert medication. Both nurses are to visualize the order (to assure the right orders are followed), the insulin bottle (to assure the right type of insulin), and the amount drawn up. The double check ends when all of these are verified for Subcut meds. But for IV meds, the verifying nurse must accompany the delivery nurse to the bedisde to watch it given. Especially for IV drips, both nurses must be present to adjust the infusion device. This is the same mechanism for all of our high alert medications.
And mistakes still happen. Don't beat yourself up. Learn by this.
Very sensible of you to have it double checked and good for you and the patient. That's why certain medications have to be checked by another person, to prevent mistakes. And you did it by the rules. Good for you.
Remember we are all human, and we all make mistakes. Only those who don't work or think don't make mistakes. You have learnt by your mistake, you will remember it for a very long time, and next time you won't make the same mistake. you will be more alert.
don't take the mistake personally, look at it as a lesson to you and your peers.
just out of curiosity, why did you use a non-insulin syringe?
several times i have grabbed a tb syringe and opened it, mistaking it for an insulin syringe, until i noticed the color of the cap. they might have been right next to each other and she grabbed the wrong one.
I was a patient in a hospital and given a IV cardiac e med that was supposed to be an antibiotic IV. I did notice my fingers turning blue and something felt wrong. I did mention it to the nurse. The nurse who took her place caught the error. The nurse who did that had many years of experience. I lived and it could have been worse. It's really to let the new nurse, mistakes do happen even after years of experince in nursing. I know a friend of mine told me that a lot of nurses who have been practicing quite a long time make some mistakes that she has seen. Learn from your experiences and go on. That's what my nursing instructor said when she told us of her med error and it was with insulin too.
Every one of us has either had a med error or a near miss. Sometimes we may not even know about it, but we are humans and we are subject to all the environmental factors that go with med errors. An older nurse generally is so in tune with the orange cap that insulin would not be mistakenly drawn up in the wrong syringe unless she was completely distracted. But there are other mistakes that older nurses are more likely to make- especially if it is something that you have not given in a long time. You feel stressed, very understandable. You will probably feel this way for a while.
I myself made a med error when I was new- Decadron was always given at 10 am, 6pm, 2 am, but this particular patient was 10 pm, 6am, 2 pm. I was working nights and I got it mixed up , gave it early. I was devastated. I discovered it when I made 6 am med rounds. Stupid, stupid, stupid. My eyes played tricks on me or maybe my brain.
Either way I know how embarrassing it is to feel that everyone thinks you are an idiot. They probably don't, but it feels that way. You will prove yourself over the coming months and it will be long forgotten. Too much happens too fast in health care to remember things for very long. There are way too many stressful events and every nurse is worrying about what she is doing or might have done wrong. You are small potatoes in the end.
I will dwell on a situation for way too long,, But I do believe it is part of the learning process to go over and over what coulda,,,shoulda,,woulda,,,and will be different the next time...you did the right thing by double checking,,the fellow nurses will appreciate that soon,,,you saw a temporay reaction from them,,,I think from experience that they were more thinking about the consequences of what if that dose had been given,,follow-up,,etc
Quit tearing yourself up about it!! But self examination after the incident is good for us,,it can help us explore variations on the theme,,and make us better nurses,,you and others like us need to learn when to put it away and say "I'll sure never do that again!!'
I grabbed a 3ml syringe last night while rushing to my last med pass. I never got a chance to even look at what I was holding because another nurse saw me with the insulin vial and asked me what mistake I just made. I felt pretty embarrassed too.
This is nursing, we make mistakes, some greater than others. I know I wouldn't have administered the dose since I would have never been able to draw it up without a leur lock sq needle, but I took another lesson from what happened to me. From now on, I will not rush when gathering important supplies such as syringes, and will pay close attention and ask if I can help with anyone who rushes in and out of the med room.
Thank you for posting this, many people have made the same mistake as us, and some will do so in the future.
Your posting this may have prevented some, I just hope the rest are as lucky as we are, and as good at following protocol as you were.
Don't beat yourself up- it's a mistake you will never make again. It's really nice when someone discreetly tells you - you are about to make a mistake or when you are doing something wrong.
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SamyRN
35 Posts
Sabinacrn,
Don't believe for a minute that nurses around you haven't had similar "near misses" or worse. That's all it was. Not to belittle the issue by any means.
You sound like a great, conscientious nurse. Don't loose sight of that.
And, I don't think it's a bad thing to "not completely relax" when performing your nursing duties. To be complacent in our daily tasks is not a luxury afforded in nursing...
You are going to be just fine.