I feel so stupid. Mistake in the PICU

Nurseadam · Aug 23, 2012

My problem happened in PICU. But I wanted to vent to you guys - I'll tell you why in a sec.
I made a mistake and I feel so depressed I don't know what to do. I came on shift and had pt. supposed to go to the floor. He was on RA but from the moment I came in he kept de-satting to 85% or so. Re-position encourage to deep breath - sats went up. But 10 minutes later same thing. Parents were the extreme worry type - out the door every 2 seconds. I called the doc - she came in said he looked ok and didn't want any O2. Ok I tried. Parents were requesting the PRN dilaudid for pain - I explained to them I wanted to try his PO meds d/t he was shallow breathing as it was and I didn't want any respiratory depression especially going to the floor and the nurses aren't sitting right outside the door. Bottom line it took forever. His TPN and lipids were almost due to be changed and floor nurse wanted them changed before he came up. Finally he's ready to go up and at that exact moment I get a kid in from the OR - open abd, intubated, sedated but just barely. Opening his eyes and turning his head. Stomach is distended and firm. His CVL dressing is soiled and non occlusive. The surgeon was explaining the child's bottom two drains weren't holding suction couldn't I figure out some way to connect his Jackson Pratt to wall suction? Kid is trying to sit up at this point. I'm worried about the pressure in his abd and surgeon is like yeah it's really firm - then he leaves. I'm afraid his CVL is going to pull out.
Long story short - I sent the first child to the floor without charting his assessment. I DID his assessment and other than the de-sats he was fine. neuro appropriate, well perfused, CL lung sounds bilateral etc. I gave a full report to the floor nurse. But I meant to go back and chart the assessment but I never did. 4 people mentioned it to me this morning and I heard 2 other people talking about it. Apparently everyone knows.
I went from ED to PICU about 4 mos ago and I hate it. There is SO much preventative care - which is important don't get me wrong. But there's so much pt positioning and bathing and diaper changes and foley care, dressing changes and linen changes and oral care and SCD's on and off - I don't like doing all the maintenance crap. I like STABILIZING then they go away. And it's the same pt. ALL NIGHT LONG. I realize I'm an ED girl - treat em and street em. Go home or go upstairs :-) And the attitude here toward ED nurses is that we are idiots. And now with this mistake I feel even more like incompetent outcast.
I'm sorry for the long post - but it has made me feel so much better just to vent. Thank you for your patience.

lol, don't be hard on yourself. it's not the end of the world. why did you transfer to the PICU?

usually if i forgot to chart something, i can pull up the chart back on the computer and do it, matter fact, if it's paper charting, i would take a 5 min to go up to that floor, pull that chart out and chart whatever i missed. It won't take anytime, and i doubt anyone is going to resfuse to hand you the chart.

Double-Helix, BSN, RN · Aug 23, 2012

A documentation mistake is probably the best mistake you can make in the PICU. Sounds like you did an excellent job prioritizing your patient care and making sure that their medical needs were attended to first.

I've forgotten to chart things many times. Usually someone brings it to my attention so I go back to the chart and add in a late entry (paper documentation). If the kid has already been discharged then the chart is in medical records and you just hope it doesn't get audited. So if this kid is still admitted you should be able to go back to the chart and add your assessment. I'm sorry that your co-workers were so belittling of your mistake. I assure you that they have made mistakes as well.

If you're not happy in PICU and would rather be in the ED, I'd encourage you to find a way back there. It's so much nicer to come to work knowing that you love what you do. All the best! :hug:

ERNurseRN5316 · Aug 24, 2012

Why I went to PICU? - well I applied for ED. Then I took the pediatric assessment test and did well so the recruiter suggested PICU. I thought it would be kinda like the ED just more intense. It's very different but I know how much money the department spends orienting new employees so I feel kinda guilty about leaving. I mentioned to my manager that I wasn't happy and she wasn't keen on the idea of me leaving so I said I would wait and see. I left my previous hospital b/c of the pt. ratio. It was 1 to 7 and we frequently had unstable ICU holds plus our 6 other patients. It was crazy. Thanks again for letting me vent. I feel better tonight. Nobody is acting weird to me like they were last night.

oh yeah and I did the charting the next night as soon as I found out. I put in my full assessment - it ended up being approx 22 hours late. I was told it's a fireable offense. I'm still waiting to see the fallout.

Guest343211 · Aug 28, 2012

OK, in general there can be a huge difference even between personality types in ED vs. ICU, especially PICU. Yes, there is a lot of maintanence care, as you state, but there is a lot of potential for deeper leaning about disease pathophysiology and treatments. I learned more in all the ICUs I worked then anywhere in 20's years of nursing--that includes pediatric and pediatric cardiac. But here's the thing. ICU nurses are extremely anal-retentive--very particular over everything--and especially in peds, there is is usually a reason for it--but even in adult critical care units, people can be very picky. I think it is the nature of the beast. ED you generally hit what's most important and move em along. Intensive care is very much combing through and covering everything. You become intimately aware of each patient from one body system to the next. There's a lot of detail orientation involved in critical care--and generally speaking, the younger and/or more critical the patient, the more careful one has to be about the details and maintaining them. In these areas, surgeons and all sorts of specialists and residents and fellows of all sorts are combing over the documentation. It is recorded at the very least in most places, hourly--but depending upon acuity, it could be by the minute. Everything is combed over in great detail--again, the nature of the area. That's why they made a huge deal about your assessment documentation.

I don't necessarily think they will fire you, but you had better believe they will watch over ever stitch of documentation and everything you do. Especially in pediatric icu's, you are in a bubble and are watched all the time. Most places--regardless of type of area--are being video-recorded. Shoot, I even do home-care cases, and many of these parents have videos w/ or w/o audio on and around their babies. It's hard for me to blame them at all for this, given the nature of the world and the fact that it's their children or loved ones. I just figure if I am doing what I a supposed be doing, I could care less if they are recording me. So what I am saying is that all areas anymore have much closer surveillance than years ago, and also in critical care units, it's like just about every RN and person there thinks they are human recorders, watching every move you make. It's something you have to accept in order to work there, and there are times that this close surveillance could save a patient's life or prevent needless errors. If you want to really learn in these areas, accept this culture as your friend. It's kind of like I had to give up a huge amount of autonomy in going from adult critical care to pediatric and neonatal critical care. I wanted to learn it, so I accepted the differences, and I realized that they were almost always in the patients' best interests.

I agree with Ashley in that a documentation mistake is probably the best mistake you can make--although, you have to remember that a ton of people (physicians and others as mentioned above) are combing through your documentation--and in reality, they really depend on it. They should see the patient of course and talk with nurses and relevant others if it is going to affect the plan of treatment, still, your documentation could effect the plan of treatment or cause the current one to be brought into question.

Learn from it, and give it another few months unless you desperately hate it. If you do hate it and don't see that changing, keep working well at the position you are in now and start looking and getting your resume out. I agree that you shouldn't beat yourself up--especially over something like this.

I am just sharing what I have seen about how the critical care culture rolls over the years.The interesting thing for me is, though I can be anal-retentive about certain things, it's more selective or based on priority. That kind of makes me more like an ED personality. OTOH, I really like the sleuthing side of critical care--being the detective and combing through information and matching it with the minute-to-minute presentation and critical values of the patient. That part has always been interesting to me. You have to find what works for you, but then deal with the cultural dynamics that are in place, b/c you are not going to change them--at least not immediately or anything close to immediately.

Good luck.