Kicking myself...

[iloveny68]

Hello - I am in my first week out of orientation, and on my own with a 5-6 pt workload on a busy med-surg unit. I love the unit, the work, the crazy pace, my co-workers, etc. However, I am beating myself up tonight over my day yesterday. I won't go into minute detail about how busy the morning was with assessments, meds, pain med requests, etc. Our pts are constantly being transported in and out for various tests and procedures. Well, I don't know where my brain was, but I was sending a pt down for a CXR who was on 2L of O2. Some transporters hook up the O2 (although with it technically being a "med", I know they are not supposed to). Normally, I do it myself, but for whatever reason I handed the tubing end to the transporter and told them she's on 2L. Long story short, I get a visit later that morning from my charge nurse and risk management to tell me that the O2 was never turned on. Patient was fine - suffered no ill effects (thank you Lord!), and I swore on my children to the risk mgmt rep and my charge nurse that this would never happen again (and for the 4 subsequent trips this pt took that day, I made sure I hooked it up, tested it, noted the remaining amount, etc). I totally realize the seriousness of the error, and am thankful that no harm was done, and I learned a very important lesson. No report was filed, and my charge nurse even shared a story with me about that happening to a family member of hers at the same hospital. Knowing I could have killed a pt was a real slap of reality. Part of me feels like an incompentent, unsafe, joke of a nurse - and the other part of me knows that I need to move forward with the knowledge that it won't happen again, and that I am on notice now to pay greater attention to everything. I just feel sick to my stomach thinking about it. Sorry if my post has no point other than to vent. Telling the story to my husband just isn't the same, you know? Thanks for listening...

[amarilla, RN]

Aww, OP.....:hug: Don't beat yourself up! It happens to everybody, particularly on dayshift, (truly brutal.)

I have been on my own for a few months now and can tell you that it does start to come together as you accumulate shifts and experience. Pretty soon, you'll do that spot check on a patient leaving the floor on auto pilot without even realizing it, (chart, order, consent, checklist, tracing the tubing, checking O2, noting time of departure from floor, etc.)

I know it's scary to feel that things can slip by but this was a very small boo boo that did no harm! You saw, you learned, and I bet it'll never happen again. When I was in my last week of orientation, I was rushing with 6 patients, (2 to be discharged and a new admit on the books that they were pushing me to open a bed for), and let the patient leave with our tele monitor! I had to call the patient's relative's cell and ask them to return to the parking lot so I could come to claim it and avoid the (horrific) fine for losing it.

My coworkers still tease me about that every time I discharge a patient with tele, but you can bet it will never happen again. Yours won't either.

[IndtrpRN]

Very small error!!! Dont even worry about it. Any honestly most transporters will put on O2..it isnt hard. All ours do at my facility!

[jmqphd]

It seems to be a huge reaction on the part of management/administration for an oversight that sent a stable patient to CXR without 2L/min O2. Yes, it was wrong. Yes, you swear to do better and having made that mistake, you learn to never do that again.

BUT... if a patient's oxygenation status is so fragile that a brief period on room air would be critical, maybe they should have had a bedside/portable CXR.

Maybe that is the issue... was this patient stable? Was there a possible reason that this brief period on room air could be dangerous? Was the patient symptomatic? Was he/she SOB or having chest pain? If the leadership got their panties in such a wad, did anyone bother to do vital signs? Had the patient desaturated on room air????

Like I said, I wonder what the leadership was in such a snit over?

[iloveny68]

No, the patient was fine. In talking with others, it seems that this is not the first time someone has made an error like mine. Happy ending to this story (other than that patient was fine!): I had to transport another pt later in the week that was on o2 via face mask. I filled out my slip, and the transporter passed it across the desk and said: "I brought you a full tank - you need to sign that I did." I very nicely said that I needed to step around the desk, look at the tank, and hook everything up myself before I'd sign anything. She and I walked down to my pts room together and she thanked me and said I was one of the few nurses that had ever filled out/signed the form on the o2, and actually checked the tank. I said "Well, I got burned big time, and was lucky, so I've learned my lesson!"

[kayern]

Let me tell you a different story. Several years ago, one of the staff nurses went into a patient and found him totally unresponsive. Seems she asked the assistant to reconnect the O2 for a COPD patient and the assistant turned the gauge to ten liters. Luckily we saved the patient but as stated earlier, treat O2 as a medication.

In my institution, transporters have a log that nurses need to sign when sending or receiving patients. I can't tell you how many times I witnessed nurses just signing with checking to see if the patient is on monitor, o2 IV pump, etc.