Just sick over mistake

[RNmom08]

Hi there. I'm a new nurse as of December. I had 3 months of orientation on my unit and have been on my own for a while. Lately I have been having some major anxiety over possibly making mistakes and yesterday - it happened.

All day long we were trying to unclog a central line (we as in me and another nurse who is orienting to our unit - she has been a nurse for 5 yrs) Our unit is very small - sometimes there's no patients and we're closed and we're floated and during the summer "normal" patient census on the floor is approx 3 pts. Yesterday there were 2 patients. One of the patient's that came in was a new protocol pt that we had never had before. The protocol comes from a university hosp. This is a cancer patient. Started running a fever and came in. So, central line would flush but was unable to get blood return. Heperin per protocol was ordered - still did not work. t-PA was ordered. That was an issue as I wasn't familiar with it and the orientee had in the past been certified to do it but never actually done it and now it wasn't up to date for her. The nursing supervisor had never done it. Per policy someone certified was supposed to do it. We finally found someone who was certified but wasn't happy about coming in. She came in and then told us that that policy is outdated and she would insert the t-pa and then after 1/2 hr we were to see if it worked... She left and the orientee who had once been certified drew and was able to get slightly blood tinged saline. I notified doc and t-PA was ordered again this time to let it stay for 120mins. Orientee who was once certified in this administered the t-PA and then she said that she was done with her paperwork that she was doing so I could finish up and she left. I paged the nursing supervisor and he stated that he had never done it and didn't know how to do it. We got out the procedure book and learned how to finish and did it. It worked this time. I was then able to page the doc and let him know it was working.

I asked him at this time about transfusing platelets to the patient (hgb was 7.9 and he ordered it in the a.m. - by the time we got blood return it was late afternoon) He said - & I quote - "No, no, no, we need to get a blood culture drawn on this patient. You are not to transfuse platelets." I repeated his order to me per telephone 2X and he said yes, that's right. I said even with 7.9hgb. He said, "Yes. We need to get the blood culture to find out what's going on with this pt." I said ok.

I get a call this am (I'm not working today) about why the platelets weren't given and that I made a mistake by misunderstanding the doc. On top of that, I have been worried the whole time about me not being certified to use t-PA to declot a central line and feeling like I had to do it anyways.

I want to get better at all of this and I want to learn the correct way to do everything. I hate the mistake I made with the order of platelets and I'm wondering if I should even be trusted to be a nurse at all. I'm just sick about this all.

Do I talk to my nursing manager about more education but then will they feel they made a mistake in hiring me? Maybe they did... Any thoughts/advice would be appreciated. Sorry this is so long...

[BinkieRN, BSN, RN]

You did exactly what you were orderd to do which was "not" to infuse the platelets. TORB = telephone order read back. That's all you can do. If the doctor denies giving you that order then he is the one who has made the mistake and is being dishonest.

You called someone to come in and administer the t-pA. I don't see why retrieving back out of the line would have to be a certified person. We do it without a "certified" person we all just get orientated on the procedure.

Don't be down on yourself, you did NOTHING wrong. Things happen in nursing all the time and there will come a day when you make an error, hopefully not a serious one, but we've all made mistakes but we do far more good for our patients by remaining a nurse.

[RNmom08]

Maybe I'm just being paranoid and hashing it over in my head to much. Ruminating is bad for me right now... I don't want to think the worst but it's so hard not to as a new nurse. I'm in a unit with all but a couple seasoned nurses. 2 of the nurses have one year experience. But ALL of them grill me during report on everything - why didn't you do this, I would have done this, Next time you should do this, don't do this, did you do that, and on and on... One time it was so bad that one of them (a nurse for 20 yrs) started making me think that a humerus was in the leg when she asked me (about a broken humerus) have you initiated PT to do crutch therapy with the pt yet? I just sat there dumbfounded, second-guessing myself about what I had done all night with the patient and said "No. I didn't. I didn't think I should." She rolled her eyes at me and said why not? I replied very sheepishly - "Because I didn't think it would help her arm."

I am 8 months into nursing and this is the first time I have started crying about my shift and really truly questioned my ability. I'm scared to even go back now.

[christina11]

I can relate to all the second guessing. I am a new nurse as well, was orienting on a med/surg floor and had difficulties with my preceptors and just an overall lack of support. I tend to think the worst of myself anyway, and having people micro-manage me to exhaustion just brought out the worst in me. And the staffing ratio on the floor I was on was anywhere from 1 nurse to 7-10 patients which was a load that I couldn't begin to handle. A long story short, I decided to resign the position, and it should come as no surprise that I've second guessed this decision quite a number of times! But, in my heart of hearts, I knew that more was being asked of me - on several levels - than what I could reasonably handle. All in all, a disappointing ( understatement! ) first experience.

[blondy2061h, MSN, RN]

Why would you want to transfuse platelets for a low hgb? We generally transfuse PRBCs for a hgb below 8 and Platelets for a platelet below 10.

Also, being certified to give TPA sounds ridiculous to me. It's a standing order on almost all of my patients. The dose given to unclog a central line is minimal- 2mg. Our policy is to put it in, wait 30 minutes, try and draw it back, and leave it in if we don't get a blood return than keep trying to draw it back q30minutes.

I can totally see the doctor wanting to work up a hgb of 7.9 before transfusing, however, if the patient is on chemo, this is an EXPECTED finding- not at all unusual. It'd be like working up why a diabetic was hyperglycemic or an asthmatic wheezing instead of treating it. 7.9 really isn't that low for a cancer patient.

In the future, document your convo with the doctor: "No transfusion given for hgb of 7.9 per order from Dr. Smith." If anyone asks why you didn't go it, "Because I didn't have an order."