I feel like the most incompetent nurse ever right now because of an incident that took place yesterday. I work on a Tele unit. I was on vacation for 12 days and yesterday was my first day back. I think that after being away for so long, everyone always takes a few hours to get back in the groove. Anyway, at the beginning of the shift I noticed that the section that I was assigned to had 2 empty beds and the other nurses had a full section, that means I was guaranteed at least 2 admissions. Now on a normal day I would have said something and asked for another patient so both me and the nurse beside me would have 4 patients each plus an admission. However because I was just coming back and I new the other nurses were tired, I said its no big deal, I'll do the 2 admissions.
Ok, so I got report, on one pt that we all knew because he was here for a week 2 wks ago, the night nurse told me that he was on a new "antibiotic" and it was running as we speak, I should take it down when it was finished so I agreed. After report and early morning assessment, I decided to go get all my patients' meds. I noticed the med in question (I forgot the name) and thought it did not look familiar. I made a mental note to look it up later before I administer it because it was due to be given at 2pm and it was only 8am. Also, there was none on the floor so I had to call the pharmacy to bring it up.
Anyway, the morning started to get busy, I had a transfer from the CCU, then I had another admission from the Cath Lab and to top it off they decided to discharge one of my other patients. I still had to do the other nursing duties such as administering meds, patient care, going to rounds and of course the regular dcumentations. In the midst of this, one of the pharmacists was making her rounds and I remembered the med so I went over to her and asked her if she could bring it up for me, she asked me what it was and I read it off the comp to her and she said sure, she would verify it and get it to me as soon as possibe and she did.
So now the empty bed where the discharged patient was had another patient coming up. This makes my 3rd admission! So now I'm getting overwhemed and the nurse beside me sees this and offered to do the admission paperwork for this new patient. I then went and administered the 2pm meds. I remember while administering the med, which I did not get to look up because now I'm overwhelmed, tired and hungry. I said him, "they're giving you a new antibiotic now?" and he said yes. I didn't think much of it also because this was the third dose he was receiving without any adverse reactions and he did not seem like anything was wrong with him. He was ambulating in the hallways and to the family room most of the day like he normally does. He also complained about the food and I ordered him something else. No reason for me to think something was wrong with him. No muscle pains, weakness,rashes, respiratory or cardiac distress at all.
Anyway, this morning, I'm off today, my nurse mgr calls and said the "antibiotic" was actually a paralytic used in the OR and the doctor who prescribed it prescribed it for the wrong patient. This med apparently should have never even been brought to my unit. Now this is going to be a peer reviewed case and she doesn't know what is going to happen with me and the other nurses who were involved in his care, the prescribing doctor and the pharmacists. I agree, I was wrong and I'm not making any excuses, I should have looked it up. I shouldn't have trusted what the night nurse said, not that she's a bad nurse, just that you never know. Thank God, the patient did not show any adverse reaction but I still feel lower than dirt right now.
Specializes in Pain Management, FNP, Med/Surg, Tele.
By the way, epocrates is free.
I believe the MPR app on Blackberry is free as well. I don't remember if I paid for it or not. I've been using it for yrs . I'll look into epocrates as well.
Specializes in Pain Management, FNP, Med/Surg, Tele.
It's better to give the med late to look it up (or you could've asked the pharmacist or even called them back to ask).
It wasn't a matter of giving the med late or not. I was administering everyone's meds. At the institution where I work, we have a one hr window before and after the assigned administration time. The issue is that I spoke with the pharmacist in person and showed it to her. She then hand delivered it to me so obviousy she didn't have a problem with it considering that she looked it up no? She should have picked up on it and told me I can't have it. I shouldn't have to call them. I have called the pharmacy to ask questions in the past.
Specializes in Peds Urology,primary care, hem/onc.
Every nurse makes at least one med error in a situation like this when we are too busy, have too much going on, your gut tells you something is wonky with a situation and you do not listen to it and instead try to get all of your work done. Happened to me, happens to most people at least once in their career. When it happened to me I learned some things. 1) LISTEN to your gut, if it feels wonky it probably is and it is OK to stop everything and figure out why it feels wonky. Your gut will SAVE you in the mass craziness that is nursing today. It is your subconsciousness trying to get you to slow down and pay attention to something. The longer you are a nurse, the more honed in this gut feeling will be. Trust it. Yours told you that something was not right with that med. SO you HAVE the skill (not everyone dose). Use it!!! Easy to want to ignore it when a million things are going on. 2) Before I gave any med (and I still do this when writing scripts as a PNP), I stop for 2 seconds, read the name of the med, the name of the patient, check allergies and WHY I am giving it. EVERYTIME. ex"OK this vanco for Joe Schmoe, he is only allergic to amoxil so I am good and I am giving it for his cellulitis" If anything in the sentence seems wonky STOP!!! If it is late, rather late than wrong. I have caught so many errors that way and have caught myself about to hand a script I wrote incorrectly to a patient. 3) Along with the follow your gut thought, if you come on and your assignment is unfair, it is OK to SAY something! It should not matter if you have been on vacay or not. Unfair assignments lead to things like this happening. You do not have to be the nice guy all the time. 4) When you are multitasking 20 things and running like a chicken with no head... you know that frantic feeling you get? When I get that feeling, I know to pay extra attention b/c that is a signal I am moving WAY to fast and I am going to make a mistake. Goes a long with that follow your gut thing. When I am in frantic mode and I am giving/writing a script... I stop and really focus. Kind off like "run, run, run, do a task, do a task, on auto pilot WAIT I am giving a med STOP- repeat the sentence above- give med- ok back to running like a nut. Finally 5) Give yourself a break. I feel everything happens for a reason. Be great full that this did not turn into a sentinel event, patient was fine and you now have learned SO much that is going to save you for the rest of your career. I have seen these things happen for the first time to nurses and the outcome was bad and the consequences were not good. Peer review is supposed to be a learning experience, not to point fingers/lay blame. You have that gut instinct, so you can trust it. You will be fine and you will never make the mistake again!!!! Hard as it is, try to see some of the positives here in how lucky you are and how much you are learning!!! Hang in there!!!!
Specializes in Pain Management, FNP, Med/Surg, Tele.
What was the name of the med?
I'm going to look at my notes when I go back to work this Friday and tell you guys. I don't remember it now because it was the first time I saw the name.
Specializes in Pain Management, FNP, Med/Surg, Tele.
Every nurse makes at least one med error in a situation like this when we are too busy, have too much going on, your gut tells you something is wonky with a situation and you do not listen to it and instead try to get all of your work done. Happened to me, happens to most people at least once in their career. When it happened to me I learned some things. 1) LISTEN to your gut, if it feels wonky it probably is and it is OK to stop everything and figure out why it feels wonky. Your gut will SAVE you in the mass craziness that is nursing today. It is your subconsciousness trying to get you to slow down and pay attention to something. The longer you are a nurse, the more honed in this gut feeling will be. Trust it. Yours told you that something was not right with that med. SO you HAVE the skill (not everyone dose). Use it!!! Easy to want to ignore it when a million things are going on. 2) Before I gave any med (and I still do this when writing scripts as a PNP), I stop for 2 seconds, read the name of the med, the name of the patient, check allergies and WHY I am giving it. EVERYTIME. ex"OK this vanco for Joe Schmoe, he is only allergic to amoxil so I am good and I am giving it for his cellulitis" If anything in the sentence seems wonky STOP!!! If it is late, rather late than wrong. I have caught so many errors that way and have caught myself about to hand a script I wrote incorrectly to a patient. 3) Along with the follow your gut thought, if you come on and your assignment is unfair, it is OK to SAY something! It should not matter if you have been on vacay or not. Unfair assignments lead to things like this happening. You do not have to be the nice guy all the time. 4) When you are multitasking 20 things and running like a chicken with no head... you know that frantic feeling you get? When I get that feeling, I know to pay extra attention b/c that is a signal I am moving WAY to fast and I am going to make a mistake. Goes a long with that follow your gut thing. When I am in frantic mode and I am giving/writing a script... I stop and really focus. Kind off like "run, run, run, do a task, do a task, on auto pilot WAIT I am giving a med STOP- repeat the sentence above- give med- ok back to running like a nut. Finally 5) Give yourself a break. I feel everything happens for a reason. Be great full that this did not turn into a sentinel event, patient was fine and you now have learned SO much that is going to save you for the rest of your career. I have seen these things happen for the first time to nurses and the outcome was bad and the consequences were not good. Peer review is supposed to be a learning experience, not to point fingers/lay blame. You have that gut instinct, so you can trust it. You will be fine and you will never make the mistake again!!!! Hard as it is, try to see some of the positives here in how lucky you are and how much you are learning!!! Hang in there!!!!
Aaaaawwwww, thank you rnsrgr8t for the words of encoragement and great tips. I'm going to practice talking out everything I'm doing when I start getting overwhelmed or dealing with something unfamiliar as well. That's a really good idea because chances are, if it doesn't make sense when you say it then it probably isn't right. And I will always follow my gut. Sadly,maybe it took a case like this to slow me down.
Specializes in Peds Urology,primary care, hem/onc.
Aaaaawwwww, thank you rnsrgr8t for the words of encoragement and great tips. I'm going to practice talking out everything I'm doing when I start getting overwhelmed or dealing with something unfamiliar as well. That's a really good idea because chances are, if it doesn't make sense when you say it then it probably isn't right. And I will always follow my gut. Sadly,maybe it took a case like this to slow me down.
AWWW you are welcome!!! Been a Nurse for 13 years and a PNP for 6....gotta share some of my mistakes so others can benefit right? Remember, it happens to everyone. The day you think you are immune to making a boo boo...man are you going to make a doozy!!!! Any experienced nurse will tell you, trust your gut!!! Someone else told me this one, "if you have to jack with it, STOP!!!!" I personally like noting wonkiness better. Love that word! It is SO perfect!!! You will be fine. The scary nurses are the ones who make a mistake like you did and are oblivious to the seriousness of it and want to point fingers to everyone else but themselves. Have a glass of wine tonight and good a get night sleep tonight. Go pamper yourself tommorrow on your off day and get a good pedicure to pamper those tired feet!!!
Specializes in Pain Management, FNP, Med/Surg, Tele.
AWWW you are welcome!!! Been a Nurse for 13 years and a PNP for 6....gotta share some of my mistakes so others can benefit right? Remember, it happens to everyone. The day you think you are immune to making a boo boo...man are you going to make a doozy!!!! Any experienced nurse will tell you, trust your gut!!! Someone else told me this one, "if you have to jack with it, STOP!!!!" I personally like noting wonkiness better. Love that word! It is SO perfect!!! You will be fine. The scary nurses are the ones who make a mistake like you did and are oblivious to the seriousness of it and want to point fingers to everyone else but themselves. Have a glass of wine tonight and good a get night sleep tonight. Go pamper yourself tommorrow on your off day and get a good pedicure to pamper those tired feet!!!
Your right, its a learning experience. Its all good, like one person said before, "this too shall pass". You know what? I haven't had a mani or a pedi in a really long time so I'm going to take this advice too and go. I can't do the wine tonight, l'm going to take Tylenol for my headache, lol. I'll do the wine this weekend, hehe. "Wonky" sounds good to me also.
I feel like the most incompetent nurse ever right now because of an incident that took place yesterday. I work on a Tele unit. I was on vacation for 12 days and yesterday was my first day back. I think that after being away for so long, everyone always takes a few hours to get back in the groove. Anyway, at the beginning of the shift I noticed that the section that I was assigned to had 2 empty beds and the other nurses had a full section, that means I was guaranteed at least 2 admissions. Now on a normal day I would have said something and asked for another patient so both me and the nurse beside me would have 4 patients each plus an admission. However because I was just coming back and I new the other nurses were tired, I said its no big deal, I'll do the 2 admissions.
Ok, so I got report, on one pt that we all knew because he was here for a week 2 wks ago, the night nurse told me that he was on a new "antibiotic" and it was running as we speak, I should take it down when it was finished so I agreed. After report and early morning assessment, I decided to go get all my patients' meds. I noticed the med in question (I forgot the name) and thought it did not look familiar. I made a mental note to look it up later before I administer it because it was due to be given at 2pm and it was only 8am. Also, there was none on the floor so I had to call the pharmacy to bring it up.
Anyway, the morning started to get busy, I had a transfer from the CCU, then I had another admission from the Cath Lab and to top it off they decided to discharge one of my other patients. I still had to do the other nursing duties such as administering meds, patient care, going to rounds and of course the regular dcumentations. In the midst of this, one of the pharmacists was making her rounds and I remembered the med so I went over to her and asked her if she could bring it up for me, she asked me what it was and I read it off the comp to her and she said sure, she would verify it and get it to me as soon as possibe and she did.
So now the empty bed where the discharged patient was had another patient coming up. This makes my 3rd admission! So now I'm getting overwhemed and the nurse beside me sees this and offered to do the admission paperwork for this new patient. I then went and administered the 2pm meds. I remember while administering the med, which I did not get to look up because now I'm overwhelmed, tired and hungry. I said him, "they're giving you a new antibiotic now?" and he said yes. I didn't think much of it also because this was the third dose he was receiving without any adverse reactions and he did not seem like anything was wrong with him. He was ambulating in the hallways and to the family room most of the day like he normally does. He also complained about the food and I ordered him something else. No reason for me to think something was wrong with him. No muscle pains, weakness,rashes, respiratory or cardiac distress at all.
Anyway, this morning, I'm off today, my nurse mgr calls and said the "antibiotic" was actually a paralytic used in the OR and the doctor who prescribed it prescribed it for the wrong patient. This med apparently should have never even been brought to my unit. Now this is going to be a peer reviewed case and she doesn't know what is going to happen with me and the other nurses who were involved in his care, the prescribing doctor and the pharmacists. I agree, I was wrong and I'm not making any excuses, I should have looked it up. I shouldn't have trusted what the night nurse said, not that she's a bad nurse, just that you never know. Thank God, the patient did not show any adverse reaction but I still feel lower than dirt right now.
What do you guys think?
I've been racking my brain over this........in the OR and in ICU we give paralytics all the time for various reasons. This medication can only be given to intubated patients since it is a neuromuscular blockade....... patients cannot breath sponateously when receiving this medication. This man (your patient) was not only breathing but he was talking to you as well.
I am wondering what med it was........paralytics don't come in piggybacks.......and they are almost always labelled "for intubated patients only".
I am thinking your manager may have given you the wrong class of medication.
Specializes in Pain Management, FNP, Med/Surg, Tele.
I've been racking my brain over this........in the OR and in ICU we give paralytics all the time for various reasons. This medication can only be given to intubated patients since it is a neuromuscular blockade....... patients cannot breath sponateously when receiving this medication. This man (your patient) was not only breathing but he was talking to you as well.
I am wondering what med it was........paralytics don't come in piggybacks.......and they are almost always labelled "for intubated patients only".
I am thinking your manager may have given you the wrong class of medication.
She probably did give me the wrong info, she has given us wrong info before. Like I said, I wrote down the name on my notes because I was planning to look it up. I will tell you guys what is Friday when I go back to work. I bet it's not a paralytic. I will also look it up for real this time :)
But I know what you're saying though, check all meds. I "normally" do.
That's precisely the point... The problems occur when things are "abnormal" and the system - not the individual - is primarily at fault. The "be more careful" mantra is pointless because nobody and no device is 100% reliable.
You were simply one step along a process which is evidently not sufficiently robust.
Your right, its a learning experience. Its all good, like one person said before, "this too shall pass". You know what? I haven't had a mani or a pedi in a really long time so I'm going to take this advice too and go. I can't do the wine tonight, l'm going to take Tylenol for my headache, lol. I'll do the wine this weekend, hehe. "Wonky" sounds good to me also.
tonet0908
124 Posts
By the way, epocrates is free.
I believe the MPR app on Blackberry is free as well. I don't remember if I paid for it or not. I've been using it for yrs . I'll look into epocrates as well.