I Made A Mistake

[dmarzzz, BSN]

Let me start with my background. I’ve been a nurse for almost three years. I stared off on a trauma/surgical step down unit for a year- only left to relocate closer to home. From there, I went on to a neuro ICU unit and stayed for about 10 months. LOVED the critical aspect of that unit, but the unit was cliquey and headed sown a mass exodus and I wanted to finally be on day shift. Same hospital, transferred to an ortho/Neuro/trauma floor. Was made a charge nurse after only 4 months of being on the unit, precepted. Good relationship with co-workers, management, etc. Only left because I remembered why I left the floor in the first place. Just not for me. A positioned opened up in the ER (something I’ve wanted to do since nursing school) so I decided to apply and see what happened. A day after submitting my application, I had an interview. The day of my interview, I had an offer by the time I got home.

SO fast forward to my ER experience so far. I’m going into the last week of my orientation. My hospital has two campuses on the opposite side of town. One is trauma, the other is everything else basically. Mostly strokes because it’s the only campus they can do embolectomies. I’m at the latter campus.

i had my first week at the trauma ER last week and did well. My preceptor said he thought I was ready and really only needed to work on my speed, but that all comes with time. Great. Feeling good. My preceptor on my home until says I’m ready and trusts me to go into rooms by myself.

I had a new preceptor at trauma ER this week. I also had my first lapse in patient care that was completely my fault.

We had a patient who came in with CHF. Homeless, wasn’t taking his lasix or other meds for quite some time. No PCP. + drug screen. He c/o SOB and edema. He was 97% on RA always. Lungs diminished but moving air. Labs came back- first lactic was 10.4. BNP almost 8,000. Trop slightly elevated. So MD orders fluids.

He went to CT and I guess his IV came apart at the hub, but didn’t come out. So CT didn’t restart his fluids because it was a blood bath. When he got back, my preceptor came in and asked me which IV bag was the bolus and I said the liter, when it was really the 500cc bag also hanging. The doctor put in two different orders for a 500cc bolus and then for maintenance fluids at 100cc/hr. i assumes they were both boluses. So my preceptor ran the bolus of 100 Cc/hr.

I came back into his room a little later and the charge RN, my preceptor and the MD were all in there. I walked in the room and the charge told me the mistake we made and told me he was in heart failure now. The MD used to be a nurse and was SO nice and looked at me and said “I messed up too. It’s okay. I didn’t notice his edema. We’ll just give him some lasix and it’ll be fine.” My preceptor also Said it was okay and that he was already in failure. She’d seen worse mistakes. Rechecked his respiratory status- RA, lungs still just diminished. Took him to ICU as already planned and ordered bipap just in case. Came back and filed an incident report.

I think part of it was me taking the “pick up the pace” comments and just rushing, but it’s not excuse. And I hate that it partly falls on my preceptor for taking my word for it and thinking I was competent enough to be able to read an order. I just feel like an awful nurse. I also knew he had edema and CHF and questioned why all the fluids, but never spoke up and asked. Which could have prevented all of it. I’ve never had something like that happen. ?

[JKL33]

You're okay.

On 11/16/2019 at 9:58 AM, dmarzzz said:

The doctor put in two different orders for a 500cc bolus and then for maintenance fluids at 100cc/hr. i assumes they were both boluses.

I don't think you're saying you thought that a rate of 100cc/hr met the definition of bolus, but rather that you simply thought both bags were to be bolused and didn't really know that one was supposed to be 100cc/hr. So the takeaway here is to get into the habit now of conscientiously checking every order/5Rs.

On 11/16/2019 at 9:58 AM, dmarzzz said:

I walked in the room and the charge told me the mistake we made and told me he was in heart failure now. The MD used to be a nurse and was SO nice and looked at me and said “I messed up too. It’s okay. I didn’t notice his edema.

?Yikes. It sounds like that was quite a bit of his presenting complaint.

On 11/16/2019 at 9:58 AM, dmarzzz said:

I also knew he had edema and CHF and questioned why all the fluids, but never spoke up and asked.

You will next time. ?

Carry on.

[JBMmom, MSN, NP]

Sorry you're feeling badly, mistakes happen and this isn't a particularly bad one. Your patient will likely be fine after some lasix, and with a lactic that high, they should be getting fluids anyway, I would think. We will always treat sepsis with fluids, knowing we can correct the CHF later without much difficulty.

[ArmyRntoMD, BSN, RN]

Everyone makes mistakes. Anyone who says they don't is a damned liar. The important thing is try to be a better nurse every day. You care that you messed up. THAT is what is important.

I nicely asked a new nurse bringing me a patient "okay did you give the patient blood?" (H+H was 6/18 or so). She says "well no...." So I said "okay, and you told the doctor?" "Uhhh no...." "And why not...?" And her charge nurse who was accompanying her starting complaining behind my back to my charge nurse (saying I was harassing her orientee) so I flipped my tune and said "Why did BOTH of you fail to ensure the patient was adequately taken care of? I can understand the orientee missing it but why did YOU, an EXPERIENCED nurse fail to do something so BASIC as check an H+H and give blood? This H+H was resulted over EIGHT hours ago!" Until she started whining when it was her own failure I was polite.

[CKPM2RN, ASN, EMT-P]

Until you can actually walk on water you will never be perfect, mistakes happen. Owning up and learning is what moves us forward. Someone else on this post was correct, with a lactic acid indicating sepsis the fluids were warranted, the fluid overload can be fixed but sepsis can spiral into death.

[JKL33]

On 11/16/2019 at 4:20 PM, JBMmom said:

We will always treat sepsis with fluids, knowing we can correct the CHF later without much difficulty.

On 11/18/2019 at 11:38 AM, CKPM2RN said:

Someone else on this post was correct, with a lactic acid indicating sepsis the fluids were warranted, the fluid overload can be fixed but sepsis can spiral into death.

Just making sure we all understand that sepsis is not "the" (one and only) dx with which elevated serum lactic acid is associated.

As a matter of fact in this scenario sepsis very well may not be the most likely thing, since plenty of other scenarios including pulmonary edema, respiratory failure, etc. are also associated w/ elevated lactic acid.

The line about sepsis and fluids is okay...if that's high on the list of possibilities to begin with. But it isn't okay to assume that's the problem when something else is more likely and then give a treatment that is known to worsen the actual problem. We don't start with a CHF patient who is hasn't been taking his usual diuretics and has had increasing SOB and edema --> see that he has elevated serum lactic acid --> go "sepsis" crazy and --> give him a bunch of fluids because sepsis.

[ArmyRntoMD, BSN, RN]

On 11/18/2019 at 12:29 PM, JKL33 said:

Just making sure we all understand that sepsis is not "the" (one and only) dx with which elevated serum lactic acid is associated.

As a matter of fact in this scenario sepsis very well may not be the most likely thing, since plenty of other scenarios including pulmonary edema, respiratory failure, etc. are also associated w/ elevated lactic acid.

The line about sepsis and fluids is okay...if that's high on the list of possibilities to begin with. But it isn't okay to assume that's the problem when something else is more likely and then give a treatment that is known to worsen the actual problem. We don't start with a CHF patient who is hasn't been taking his usual diuretics and has had increasing SOB and edema --> see that he has elevated serum lactic acid --> go "sepsis" crazy and --> give him a bunch of fluids because sepsis.

I see this a lot. Many nurses I’ve worked with will see a symptom and immediately assume it’s a certain disease process without understanding differential diagnosis.

Lets say a symptom is indicative of a certain condition 95% of the time. If the other 5% of the time the treatment for the 95% would lead to complications or death, do you still want to assume?

[Kallie3006, ADN]

Maybe I'm the only one confused but when someone tells or orders a bolus I generally associate that with a "large" volume in a "short" period of time. You stated that you came into the room a short while later, finding the MD, charge, and preceptor in there, and if I'm understanding correctly, the fluids was set to infuse at 100cc/hr, which would mean the patient received 200cc/hr, or less if you rounded on the patient in less than 2 hours (which I'm assuming is the case especially with being in the ED), and the mistake was found. You also stated that there was a 1L bag and a 500cc bag hanging ready to be infused, with me concluding that both bags had at least enough fluid in them to ask for clarification on which to hook up as the bolus, so pt has received less than 1500cc since both had fluid in them. Pt has an elevated BNP, edema and not medication compliant and an elevated LA.

LA elevating is one tests that is used to help with a sepsis dx but not always is an elevated LA caused by sepsis. Pt has CHF and is presumed at this point to be in CHF exacerbation (if I'm understanding correctly). When CHF is a current problem the deminished blood flow means there is a diminished oxygen supply being sent throughout the body, which the body then starts to break down carbs to meet the energy demand, lactic acid is created as a byproduct which raises the level results of the blood draw. If this is the case with this patient then sepsis may not be the underlying cause but the pt's comorbidities, which the original assessment, corroborates.

Bottom line, everyone makes mistakes, none of us are immune to them. What makes a good nurse is those that admit to those mistakes, asks questions and learns from them. Remember that and this situation will make you more aware and clinically stronger to other patients you care for, students, new nurses, or orientees you precept, will be able to have someone that is able to share their experience to heighten awareness for situations like this, that is not only encountered in the ED but with critical care and floor nursing as well. Thank you for sharing your experience and don't beat yourself up!