Infant given wrong amount of milk for first feeding...

[rosebabyrn]

Hi, I’m a nicu nurse and have been for almost two years. I recently made a mistake that’s been really eating away at me because I’ve never done something like this before. I had a 32 week infant that had just turned 24 hours old and we were going to start NG feeds. I had read the doctors note earlier that day and said they were going to start at 25ml/kg/day so I calculated what she would be getting each feed. I didn’t feed right away because I was still waiting for the doctors order and I finally got it later that afternoon and it said 25ml/kg/day (6ml/feed). I glanced at it and for some reason read it as 25ml/feed and didn’t even read any further to look at the 6ml/feed that was actually written there. So I ended up giving the baby 25mls every feed instead of the 6mls she was supposed to get and she continued to get 25mls throughout the night and part of the next day all because I had read the order wrong. They ended up holding a few feeds the next day and restarted on the correct amount. She’s fine now but I just feel absolutely horrible about it and have been having anxiety about my

mistake ever since. I don’t know what I was thinking - I even read the doctors note and calculated the feeding amount of 6mls/feed myself earlier that day and I didn’t even think to double check the order and question it when I thought it said 25mls/feed. It was such a dumb mistake and I feel absolutely terrible about it.

I’m not really asking for advice here or anything but just wanted to share because it’s really been bothering me. Has this ever happened to anyone else? Making a careless mistake just by reading the order incorrectly or not questioning something?

[JKL33]

I remember a time where I almost went through with a similar mistake but didn't thanks to being a tiny bit OCD (looking at order multiples times). It really scared me because I had probably already read the order 3 times when I realized the 4th time that I had read it wrong the previous 3 times.

It scared me enough to make me realize that looking at something and processing it/being cognizant of what one is reading are two very different things. I made it my mission to make sure I was engaged instead of just "looking at" orders I was about to implement. It was around that same time that I decided I needed to be more cognizant when doing anything with med order implementation even if it seemed like the place was burning down around me.

I trust that your experience will stick with you as mine did with me, and you will make sure you are reading and processing, rather than "looking at" important things from now on. ???

[Eeks, BSN, RN]

I know it's very anxiety inducing to make a mistake (and for good reason because that's how we prevent mistakes from recurring!). All in all, it sounds like the baby was just fine. It would be concerning that she might have vomited which could obviously be dangerous but it sounds like she didn't and ended up reverting to the correct feed amount later. Hopefully you documented your mistake as your facility advises and were honest about the incident. Sounds like your patient is fine though and I'm sure you will be more diligent about taking the moment to read the orders more thoroughly in the future.

[CommunityRNBSN, BSN, RN]

We all make mistakes, and since this one didn’t result in harm, it will really serve a good purpose by making you super super careful going forward. You’ll never glance at a med order and think “Duh, there’s no way I could mess that up” because now you KNOW you can mess things up.