I made a mistake and feel awful

[kerussll]

The other day I got an admission late in the afternoon. It was a transfer in from another hospital. Unprepped 27 weeker and Mom walked in complete. This hospital doesn't keep babies less than 30 weeks, so they let her deliver there since there was little time and transferred baby to us.

The baby arrived stable but with a lot to sort out. I had actually never admitted a baby from another hospital before, so it was pretty hectic. Baby came intubated, with UVC and UAC; fluids, meds, and drips already running, on the transport team's pumps. It was a confusing mess trying to sort out their equipment and hook it up to our pumps. Syringes without labels, unfamiliar concentrations of meds, and unfamiliar tubing. It took 3 of us to sort it out while dealing with being in isolation and constantly needing to run and grab more equipment and extra pump channels, etc. It took us quite a long time to switch over all the fluids to our pumps, then change everything as we got meds and fluids sent up from pharmacy. During all the chaos I checked to make sure lines were secure, and we got an xray straight off to check placement of lines and ETT. Doctors gave the ok that we were in good position, so we carried on working. Thankfully the baby remained stable during all this.

I had finished hanging the new fluids and meds, weaned down his oxygen quite a bit, and fully examined the baby, but had not sat down to chart a thing when 7:00 rolls around and the night nurse arrived. I introduced her to the family, then stepped outside to chart and give her report. It was not my best report. I was a bit frazzled, but did the best I could. During report I realized I had never counted back to get a centimeter marking on the UV and UA lines. (I didn't get this in report from the other hospital because the nurse didn't know them) I told her they were secure, and xray verified placement, but I didn't have the measurement written down. I know this is a mistake, and it's something I should have checked right off the bat. I felt really bad not knowing that piece of information. I should have also suggested we go in together and look at the markings, but I didn't.

A few days later I worked another shift, but wasn't assigned this baby. I checked in to see how he was doing in the morning. The nurse who had him that day told me he had a massive grade 4 bleed and they were going to talk to parents about removing support later. I felt devastated. So guilty that I could have made a mistake (in addition to not checking the lines properly) and just terrible for the family I had met the other day. I feel like if this baby had had a better nurse on admission, maybe this wouldn't have happened. I never expected that outcome. A few hours later the charge nurse came to talk to me and said that the nurse I gave report to that night was concerned about my care because I didn't know where the UV and UA were. She also complained about me not completing the MRSA swab, and said I didn't know what IV fluids were running. It was true I didn't do the swab, and passed along that it still needed to be collected, but I told her all the IV fluids and rates and meds, so I'm not sure where she got that.

So I just feel really terrible about the whole thing. Guilty I didn't do the best job on this baby, and really feel bad that the other nurse was concerned about the care I gave. I've never had anyone question my quality of care, but I've also never made a mistake like that before. I had to go to the bathroom and cry/ get myself together for a good while then, and I'm still feeling pretty shaken up about it.

Thank you for listening to the rant. Any advice you can give me would be appreciated.

[Baby Wrangler]

First of all, I highly doubt that you did anything that could've contributed to the grade 4 bleed. It's sad that it happened to the baby, but you don't have anything to do with it. That's part and parcel of being a 27 weeker. And if the baby was intubated and had a ua put in, sounds like he or she didn't have the best start for a 27 weeker, which definitely contributes to IVH. I don't think you should beat yourself up about that.

As for the UA and UV lines, I'm really surprised that the transport nurse didn't know the measurements! That's insane that she didn't know, I mean what if they had gotten pulled or whatever during transport. That along with ETT measurement and name bands are the most important things to go over. I think you've definitely learned a lesson about checking the line measurements and I'm sure that next time you'll remember to check them with the next nurse. I think the night nurse could've come up to you on an another day and spoke with you personally instead of going straight to the charge. Don't beat yourself up about it. You had nothing to do with the IVH and it doesn't sound like anything happened with the lines. Just remember to go over them next time.

[mirandaaa]

If you bog your mind down with "what-ifs" you're going to end up resenting nursing because you're always going to be thinking "what if I did this different, would the outcome have changed?"

Yes, there may have been a mistake or two, but you can't know for sure if that directly affected what the end result was. For all you know, even if these mistakes hadn't been made, the outcome may still have been the same.

This is why the "what if" game is dangerous.

Learn from your mistakes, realize and acknowledge you did the best of your abilities, and tomorrow is a new and better day.

[Jory, MSN, APRN, CNM]

The next time you get a baby in, tell the transport nurse, "I'll need you to label the lines before you leave"...she put them in, she needs to take responsibility for them. That isn't your fault. That was hers, as was the UA/UV placement.

Babies on a vent have a daily x-ray, so a UA/UV that is out-of-place gets spotted pretty quickly. However, the next nurse, knowing placement was verified, should have wrote down where they were if it wasn't charted already...problem solved. To do anything less is just plain lazy.

Sounds like you have a judgmental nurse that wanted to tattle rather than do her job. Transport admissions are tough and when you get a bad report, that is hard to correct. However, it is what it is. You can't sit there an argue with a transporting nurse on what a crappy job she did. You work with what you have an move on. The only thing I would have been insistent about is them labeling the lines. Those lines can be a mess and no way would I take responsibility for that. I would make sure they signed them too.

Did the baby receive the K injection? 27 weekers are prone to bleeds. Very common. Maternal care may have been factor as well. You never know.

[NicuGal, MSN, RN]

I used to transport and we get in quite a few transported kids. The transport nurse should know where her lines are and all those lines should have been labeled. That is the transport teams responsibility.

As as for not checking the lines, sure you should have, but it is hectic getting a kid in. You had an X-ray that said they were fine. The next nurse could have just noted the cm mark and moved on. She could have also done the swab. Nursing is a 24/7 job, things sometimes need passes on.

Sometimes 27 weekers bleed, my guess it was precipitated by something before transport, changes in blood pressure, stress, the transport itself.

its hard to not be hard on yourself. But you did what you could.

Some people live to nitpick others.

[karnicurnc, MSN, APRN, CNS]

I agree with the above posts: the transport nurse put the lines in - he/she should know exactly where they are. Nothing in your care contributed to the IVH. Being born early, in an outlying facility, and being transported in on a vent is all it takes. Period. I bet you never make the same mistake again, so learn from it, teach others, and move on. :)

[babyNP., APRN]

No, it sounds like it was a chaotic admission that you should've been given extra support. It's easy to fall into the trap of thinking that you can do everything yourself and it's often perpetuated because there are some RNs that let you drown to see yourself be "proved" that you can handle it. Well...that's unsafe. It's not okay for people to treat you like that and my program director during my NNP program said it best:

"When the nurse makes a mistake, OMG the world is ENDING and I am a TERRIBLE nurse, etc, etc. When someone in the provider field makes a mistake, it's more taken as an opportunity to learn from your mistakes."

I've really seen it to be so true. I had a mostly good experience as a RN at my first hospital but I did witness this sort of thing from time to time and saw it at other hospitals where I did some agency work. It's a complete 180 being a NNP.

Now, a lot of nursing care is supported well and I'm sure there are providers out there that are "shamed"- and what I've experienced is anecdotal (at best), but my director told us that the mindset in nursing and medicine/provider role are just very different.

TL;DR: Don't beat yourself up. It's okay. You did not do anything to harm the baby intentionally or unintentionally.

[tinkerbell419]

Aww as somebody else said, at least you know now the changes that you will make the next time. You will be making sure you obtain all relevant information about lines to the point of being obsessed because you will be conscientious about it. I can tell yoi are a conscientious person who wants to do a good job.

We can all make mistakes or get things back to front. You will remember this as an area for improvement and will make a mental note.

You will be checking those lines with an eagles eye from now on. Any more news on the grade 4 bleed?

[kerussll]

Thank you for the kind words everyone! I am feeling much better about the situation. It's still terribly sad of course, but I'm not questioning whether I caused this outcome anymore and that's a big relief. I realize I did the best I could under the circumstances, and have learned a lesson to carry on through the rest of my NICU career.

I do still feel upset that this nurse didn't talk to me about her concerns, but went to the charge nurse instead. This is actually the same nurse I had a safety concern about one day a few months ago. It appeared she had flushed a med line through, which we don't do at my hospital, so I thought she may have given a baby too much gent. I did alert the doctors to this, and we drew levels. Baby was fine. I asked her about it when she was back that night, and we straightened it out. I tried to be nice about it and told her it would be an easy mistake to make. Maybe she holds some hostility towards me for this? I don't know. I'd like to talk to her about this and tell her I'd appreciate she talk to me in the future about any concerns she has. I'd kind of like to find out why she lied/misunderstood some things she told the charge nurse that weren't true. (Like I didn't know what fluids were running. I didn't do the MRSA swab because I didn't know how.)

As far as the baby, I know the doctors talked to parents that day and they said they didn't want to remove support yet. Baby extubated himself while parents were holding that afternoon, and they said they didn't want him reintubated. So if he doesn't make it on CPAP, I guess that will be it for him

[kerussll]

Oh, and to answer someone's question: he did receive the vitamin K shot before transport.

[Julius Seizure]

If I were in your position (wanting to address this other nurse about the things she had told the charge nurse about, etc), I would probably have to find some way to not get flustered/not cry/not talk too fast/too much, because it would feel confrontational and like I might get chewed out or snapped at. I'm kind of a wimp. I think I might pretend in my mind that I was a practitioner or a doctor addressing a fellow doctor, and act how I imagine that they would - very professional and collegial - instead of one nurse to another where I might get snapped at, or responded to with rudeness or passive aggresiveness. Like another poster was saying, in nursing it sometimes feels like a blame game instead of an opportunity to learn from our mistakes. I would probably try to make it go like this:

"Hey, I wanted to talk to you for a moment about the other day. The charge nurse told me tonight that you had some concerns with my care of the baby that I gave report to you on?" (an open ended question so that the ball is in their court without being aggressive)

Then maybe they (in a bad scenario) are nasty about it and accuse you of giving a sloppy report and not having finished your tasks before leaving, etc etc.

"Youre right, I was a little scattered that day. It was a crazy afternoon, and getting a transfer admission was a new challenge for me. I appreciate you getting that MRSA swab sent though. The charge nurse said that you were concerned that I didn't know what fluids the baby was on?" (another open ended question)

Basically.....open ended, non accusatory questions. You arent speaking to them to attack and be right, its to learn and clarify any confusion and to improve things for next time. Thank them for their hard work that they did after assuming the babys care (not because you are indebted, just as a professional courtesy). And stay calm, OBJECTIVE, and in control of your emotions. Actaully, totally leave your emotions out....this is a professional discussion, not a heart to heart.

Once you have heard their thoughts and answers to your questions, perhaps end the discussion by telling them that you really appreciate them talking to you about the concerns and that in the future, you hope they will come talk to you directly.

And then I would go hide in the bathroom while my nerves calmed down from trying not to internally freak out during the conversation. (Did I mention that I'm a wimp?)