I have to meet with nurse manager

[mjs5312]

Well, I got a phone call yesterday from my nurse manager. She stated that the patient I took care of last week had an incident report filed.

He was on a drug that while was programed correctly, his weight was incorrect...thus he was getting the wrong dose.

Now, I didn't program the original dosage and I DID check that the mix was correct and was programed correctly, I didn't catch the incorrect body weight.

I have been an ICU nurse for 10 yrs and this is the first time I've had to be called "into the principal's office" so to speak. I have to get a union rep since there will be two managers present.

It's embarrassing, makes me question my competency and of course, there's the matter of the person who filed the incident report. Who did they share it with ? -

Of course, I understand the mistake, take responsibilty for it and I will be more astute with my checks of the prior shift.....

I just needed to vent.....cause it really, really bothers me on multiple levels.

[Keepstanding, ASN, RN]

oh dear, i can imagine how you must feel. i will say a little prayer for you. i hope the situation will get better for you. :icon_hug:

[jessiern, BSN, RN]

Not that playing the blame game is the way to go in any case, but I hope the nurse that entered the incorrect weight will be spoken to as well, since that is where the breakdown started?

[loricatus]

Were you responsible for a weight check at the beginning of your shift, while the incorrect dosage was running? How much of a discrepancy in weight and dosage are we talking about? I am sure that if it was that big of a difference you would have caught the dosage being inappropriate. Any adverse effects from this error? Also, I thought that a 24 hour chart check is supposed to catch these things.

Just seems like it wasn't your fault & it just isn't your responsibility to police the prior shift's actions. That's what managers and charge nurses are supposedly there for. Sounds like some buck passing is taking place. Or, is it getting close to review time and raises?

[kmoonshine, RN]

Was the patient getting too much of the medication, or were they getting too little? And was it a high-alert medication (ie insulin, dopamine)?

Most of the times when things like this happen, it's a breakdown of the system that is in place. Try to think about all the good things that you have done over the past 10 years, and all the things that you DID catch. We're human and mistakes happen, and the fact that you are upset about it shows that you care.

See this as a way to perfect your practice and do your best to move forward. Keep us updated.:icon_hug:

[RN1989]

Make sure you know what the policy is before you do. Many times I have seen this occur due to a change in the pt's wt - either up or down. Some facilities and docs want the gtt rate calculated based on that day's weight, others wanted it calculated on the original admit weight. I've literally seen fights between docs over this. And the nurses get caught in the middle because the docs aren't consistent with what they want and the nurses are going by what they did at one facility and no one even really has the policy written to reflect what is supposed to be happening. It's a mess. Know the P&P before you go. If you are in error, make sure to acknowledge you screwed up, be able to speak to how the error occurred, and tell the managers what you are doing to insure it doesn't happen again.

[sissiesmama, ASN, RN]

Were you responsible for a weight check at the beginning of your shift, while the incorrect dosage was running? How much of a discrepancy in weight and dosage are we talking about? I am sure that if it was that big of a difference you would have caught the dosage being inappropriate. Any adverse effects from this error? Also, I thought that a 24 hour chart check is supposed to catch these things.

Just seems like it wasn't your fault & it just isn't your responsibility to police the prior shift's actions. That's what managers and charge nurses are supposedly there for. Sounds like some buck passing is taking place. Or, is it getting close to review time and raises?

I agree with loricatus - While an error was made, it seems to me that the others involved should also be in on the butt chewing. I would definetly read up on your P and P before the meeting.

And one other question. Was your patient harmed due to the error? The powers that be should take that into account when they are handing down punishment.

I'll keep you in my prayers while you are going through this.

Anne, RNC:D

[leslie :-D]

my line of thinking is along w/rn1989's...

i'm wondering if there were any specific orders re pt's wt?

was it to be taken daily or was the admitting wt sufficient?

anyways, and this is just my opinion, but when meds are administered according to mg/kg, i do think it's the responsibility of ea nurse to ascertain the correct amt.

to depend on another nurse's calculations is dangerous.

i would chalk this up to yet another one of our perpetual learning experiences.

wishing you the very best.

leslie

[mjs5312]

Well, thank you all for the replies.

I got some more information regarding the incident and apparently this went on for several shifts. I only had the patient for one, but the other nurses didn't catch it either. So, we all have to be "spoken" to....Which may or may not result in displiniary action.

I guess the patient weighed 75kg and was 69 inches tall, and she put in 69 as his weight.....So it was incorrect dose.

It was FK 506 qtt for an organ transplant.

[mpccrn, BSN, RN]

this is a horrible incident, we as ICU nurses can't beat ourselves up enough for mistakes.....there is little a manager can do to top that....the meeting is probably just a mandatory thing, to acknowledge the mistake and talk of ways to prevent it. let your manager know how awful you feel and how you'll be alert to this scenario in the future.......and it's no doubt, you will be! that's really what the manager is after. if you have a good record, competent skills and are concientious, she is less likely to bite you. you are human and mistakes happen, surely she recognizes that. good luck!:icon_hug: