I made a mistake :( worried about losing my job....advice?

[claireb]

So...

I graduated in 2007. I worked in a doctor's office for two years right out of school, and have been searching for an inpatient position since graduating. I FINALLY got a job, it's an hour and a half commute from home, and its in a behavioral health facility with a psych intensive and gero-psych ITU.

There is one RN on each unit, acting as charge nurse and unit supervisor. we also have 1-2 LVNs who help pass meds. I had seven shifts of orientation, then they let me loose. I have worked about 10 shifts on my own.It has been extremely challenging being in charge when I have so little inpatient experience... but I have really been powering through it, staying safe, staying positive, brushing off when co-workiers are rude.

So today we had 12 patients with extremely high acuity on the gero unit. I was overwhelmed from the second I got there today, and I only had one LVN with me which was hard already, considering that we were understaffed, had several discharges at once, then one patient started a fight with the other, and there were injuries.

So... I had to do all these incident reports (never done one before, I had some help). There was a patient on the unit who was involved and injured so I had to call their family member. The patient's daughter said it seemed like sometimes ativan made the patient more agitated. I told the daughter I would let the doctor know and wrote it on the physician notification form.

THEN, the patient got really agitated, again, and I called the doctor to get an emergency IM because the patient was kicking and spitting. I called the doctor and he ordered Haldol 5mg and Ativan 1 mg IM. I didn't mention to the doctor what the patient's daughter said... there had been no evidence of it from what I had seen, and I thought the doctor would brush it off.... we gave the injection and the patient got extremely agitated, it was even a code grey...

I feel awful, I fessed up right away... I KNOW it was a huge mistake, I just think the combination of being so overwhelmed and understaffed clouded my judgement.... I HATE myself right now... I finally got a job and I am so scared I am going to get FIRED!

I am almost considering leaving the field over it! I feel like i must be a horrible nurse and never want to feel this way again.

Any thoughts or advice? anything would be helpful please!!

[Blackcat99]

Welcome to the "real world of nursing." I don't know if you will get a write up, suspension or fired. You did the right thing by telling the truth. Just keeping telling the truth and hope for the best. Nobody's perfect so stop beating yourself up over your mistake. Hopefully your job is reasonable and will listen to your side of the story. I wish you the best of luck.:redpinkhe

[psychnurse10]

Take this as a learning experience that is going to make you a pro at psych nursing down the road. It's not time to quit just yet, especially since you followed the doctor's orders. Benzo's such as ativan are sometimes known to actually increase agitation when used when the patient is not actually agitated at the time. It sounds like the doc gave you a PRN order to administer it IM because the patient was infact at that time in need of the drug. The doctor is also aware of the effects of benzo's and when to use them so by you doing your job and notifying the doctor you are practicing properly within your scope of practice. As far as the daughter is concerned, although it is always beneficial to listen to the family because they know the client best and can provide helpful information, it sounds like this patient needed something right away. Just because she told you this, does not mean that you did anything out of your scope. Having said that, take it as a learning experience in the future! Next time you will remember her when the doc gives you an order, you can then put the family input out on the table. At that point he may order something else, or he may stick with what he wants because he feels that it will have the highest benefit for the patient in that circumstance. The fact that he reacted like she said, the doctor ordered it. Is he on Ativan PO the rest of the time? If this is so, he is receiving this mainly outpatient right? Then that is something the he and the daughter should discuss with his primary psychiatrist or PCP. If it is something that he only gets when he comes into the inpatient setting then when he leaves his outside pyschiatrist will review the changes and more than likely put him back to his normal regime, or something similar. Bottom line is now you know. You may see this guy again because unfortunately psych hospitals are revolving doors and you will get to know him and what makes him twitch, what works, and what doesn't. If he has no indication of an allergy to Ativan or any other contraindication for taking it, although it might not be the best choice for him, there is nothing illegal about it. Rember this too, whenever someone becomes psychotic, like you and I there is something driving that. There is a change that has upset their lives and they just dont have the capacity to handle the precipitators like we could. It could be something as simple as he can't watch his favorite TV show, or something extreme such as hearing command hallucinations and he is scared so he is acting out in fear. It is helpful to get to know your patients and talk to them about their history and dynamics. It is hard to do that inpatient but as the Russian's say, "O prochenya matz o cjenya." Practice makes perfect! Good Luck!!

[Davey Do]

The patient's daughter said it seemed like sometimes ativan made the patient more agitated.

Oh, claireb.

The daughter's statement was a perspective. A subjective one. "Seemed" is the key word here. You took note of it. Told the daughter you'd let the doctor know.

Then, a situation occurred and you handled it the best you could. At the time.

Remember, you are a fallible human being. However, I don't see where a "mistake" was made. You handled the situation. You got a standardly appropriate order from a doctor. You did the best you could.

Now, in no way do I mean to brush off the family members' input here. I actively support ANY family involvement in a patient's treatment. Whether it be positive or negative. In fact, many times I have calmed an irate family member by letting them know how important their involvement is. Most people just want to feel like they've been heard and understood.

And you did just that. Assurred the daughter that she had been heard. And that you would do something about her input. But, it's like Robert Burns wrote: "The best laid schemes o' Mice and Men, Gang aft agley..."

BTW: In the Hospital where I work, the Docs often prescribe Zyprexa IM for agitated behavior. (We have to call it "psychotic symptoms".) It seems to work well. And there are less side effects than with the old standby, Haldol.

I'd just like to let you know that I've been in similar situations and thought the worst. It never happened. Hopefully, the your outcome will be the same.

In closing, I'd like to let you know how much I appreciate your method of dealing with your own anxiety about this situation- recalling it and asking for thoughts or advice. That's admirable. A sign of a conscientious caretaker.

The best to you, claireb.

Dave

[claireb]

WOW thank you so much for the helpful responses. as it turns out, I haven't even gotten spoken to about it (yet). maybe it is clear I learned from my mistake and my boss is looking the other way!!

THank you soo much everyone, helped me get through an anxiety ridden weekend. :)

[pinkiepie_RN]

We tend to use standing PRNs on my unit of Zyprexa and Ativan, but some patient end up having Benadryl, Haldol and Ativan ordered instead. Ativan can make some patients agitated, but it's often a trial and error type thing. I would recommend that this order be D/C'ed if indeed the patient was having a paradoxical reaction to it or the doctor thinks that it's inappropriate though.

[Jules A, MSN]

It happens so cut yourself some slack. :) FWIW I'm not a big fan of Ativan in gero because of the chances of it disinhibiting them.

[BabaLouRN]

Just remember.. "The Best Lessons are the Ones That Hurt The Most"

[Whispera, MSN, RN]

I agree with everything everyone said before me. I'd like to add one more thing (besides giving you a supportive hug!). The family says Ativan seems to make the patient more agitated. Might this be at times when the patient is already agitated and that's why it's given? Might the agitation already have a momentum built up that it takes awhile for the Ativan to catch up-to?

Zyprexa's good stuff. Haldol's bad in the long term since it's likely to cause EPS and is high risk for other side effects. Haldol is also often the antipsychotic of choice in emergencies because it's cheap compared to Zyprexa. Prescribers tend to think if the crisis can be managed, the patient will only get a dose or two during crisis, and then the risk isn't so great.

[Starting Over...]

I have a degree in psych so I feel confident that I can contribute to this as well even though I am not quite a nurse yet.

From what you posted, I cannot see why you feel you would get suspended, fired, written up etc....

There was a situation, you contacted the doctor, you described the situation, the doctor prescribed orders, you followed those orders.

Hopefully, you charted all of this which I'm sure you did since that is one of the responsibilities of the nurse.

Family can provide feedback and information on history, how one reacts, etc... but patients in a facility outside the routines of their "normal" family life are going to react differently.

There are so many factors involved for why this patient reacted in the way they did and so to say that meds were 100% responsible would not be right.

Hopefully, when the next opportunity presented itself, you were able to meet with the whole medical team that is involved in this patient's care to provide family feedback.

Once again I don't think you did anything wrong

[s1716698]

Dont worry, and dont beat yourself up, you did a good job,

keep on pressing on

[Yiggs]

Sorry about your "mistake." I can't see why they would fire you, it's not like the patient has an allergy to the medication; the medication had the opposite effect on him which happens a lot with elderly people. At least you can give the doctor a firsthand report confirming what the daughter reported to you. I would say it is somewhat of poor judgement since the daughter had mentioned that he does get more aggitated when he gets ativan. Forgive yourself and move on and thank God that it wasn't like you gave a medication to a patient with a "known" allergy.

It will get easier on you as time goes by. Sometimes we are harder on ourselves than others are on us. You will be a little wiser and a little more discerning when you face similar situations later on. Don't be afraid to talk frankly to a doctor about a patient's treatment or condition, and should you be given an order to administer meds that you think is too much or will harm your patient talk to your supervisor/refuse to give it becuase ultimatly, as Nurses we are responsible for our own actions or inaction! You will be fine ... say your prayers and do the best you can to stay focus!