OK. Time to share those stories when you end up feeling like a total and complete fool.
Here is mine. I still feel like a complete and total fool.
Background: I work on a rehab unit. Part of our plan of care is for pts to go out on passes (day or overnight) on weekends, to see how they can cope.
Saturday: My pt goes out for a day pass. I do the whole sign out procedure - have a good time, etc, etc,
!6:00 - Pt comes back. (or so I think)
17:00 - I go to set pt up for supper. Can't find him . Search the unit. Search the area arount the unit. Ask other nurses = Have you seen Mr X? Nope. Can't find him.
Ok move into phase one of Code Yellow (missing pt) - have him paged to return to unit.
Nothing. Tired to call family - no answer at one number, only voice mail at second. Left a message (pls call unit, can't find father, etc etc)
About 1745 move to Phase 2- all units start searching. Security comes. On-call resouce person calls. (no supervisors). Iam struggling with the stupid @!#$% computer to get the description out (computer completly froze on me 3 times.) I am in total panic mode (unusal for me - usually I am good in emergencies) I keep picturing this man lying some where hurt, or worse. ( we once had a confused pt escape thru an open window. Fell into a ditch. would have died from exposure if a nurse on the 3rd floor hadn't been looking at the window and saw him fall).
Total panic setting in.
1750 - family wheels pt onto unit. Accompanied by security. HUGH sigh of relief. I go and talk to family - you can't take him out without telling us, etc etc. Son says - we signed him out with you. I say "But you brought him back at 4:00pm. Family says NO.
Suddenly it hits me -pt I saw coming back was a completely different pt, Mr Y - who had apparently also been out on pass. Both pts were Chinese. I was occupied with dealing with another crisis when pt came back at 16:00 - I just saw a Chinese pt come back, assumed it was my pt becase I knew I had signed him out earlier. (to my defense, this was the first time I cared for Mr X, and I had never cared for Mr Y)
I apoligize profusely. Explain what happened, acknowledged my error, etc etc
I have NEVER felt more stupid in my life.
I have tried to make a joke of it - I figure, better for me to joke about it than have other people going around saying "Guess what Pepper did".
everyone tells me - better save than sorry, you did the right thing and so forth.
But I still feel so foolish! If I had taken an extra 30 secs when the first pt came back to really look, I would have seen it was a different pt.
So- that's my foolish moment of the month. Can anyone top that and make me feel better, or should I just accept my Oscar for the Foolishest Moment now??
