learning from mistakes...too many?

geekgolightly, BSN, RN · Oct 28, 2004

I was a nurse for two months before I took a year off to care for my new baby. I am back at work now in a new facility, in a new state, and have been on the floor orienting for two weeks. The last shift I worked, I made TWO mistakes. Both med errors.

I wrote down 159 instead of 129 for blood sugar after hearing the PCT say "159," and did not check to make sure it was that number. I gave 4 units reg insulin based on that. Pt was fine, on decadron adn eating up a storm so her blood sugar actually went up and stayed up all day, so it definitely didn't harm her to get the extra 4 units that day. Still, I was so shaken from this experience. I cried and my preceptor felt so sorry for me, he kept reassuring me all day that I was doing well. Whcih I knew came from feeling sorry for me rather than being proud of me.

I also, took from the PYXIS reglan and DHE and gave the reglan, but did not follow up with the DHE ten minutes later. It was 7pm, shift change, I was giving the med to a patient I was not giving report on (it was offically my preceptors patient, but I said I would give the med) so although I told my preceptor that I put the DHE in the patients med cart, I didn't tell the night nurse that information. She left a message on my machine which I didn't get until the next day saying she didn't know if I gave the med or not.

It was two days ago, and this is all I can think about.

It's nightmarish making mistakes. I can't stand it. The guilt is overwhelming and I don't know how to feel better about it. I wish I knew when the night nurse worked again, so i could ring her up. Maybe I can get her home number, so i can know what happened.

virmm1, LPN · Oct 28, 2004

I'm posting this here because the subject is med errors.

I have been LPN for 9 yrs. Worked LTC the1st two years and spent the last 7 working in drs office. I decided I needed a change and went back to LTC.Until now I have had a good nursing record. few errors, known for being concenious almost to the point of OCD. I thought I was a good nurse until recently.

In a 6 mo period I have made 1 insulin error, 4 doses not given errors all narcs.9A 9P, 9P not given,the last one was Procrit not given (hadn't came from pharmacy) for a pt with recent GI bleed, Coumadin ws held,ws having nosebleeds,nothing copious but still. I am now unemployed (resign or be fired). Thankfully none of the pts were harmed.

I am having a hard time finding LPN refresher courses in my area. Google said I should look at the hospital where I went to school, I was told they don't offer them. There is a nursing program at the local community college where I could take some classes but I need to learn quicker than a couple of times a week. I am reading everything I can get my hands on re med administration , documentation etc but I feel like I need something concrete to prove I can safely practice my profession.

I also need to work but am afraid to get another nursing job in light of the recent errors. I want to nurse but not being a danger to pts is my first priority.

Any ideas, suggestions , professional opinions are appreciated.

virmm1, LPN · Oct 28, 2004

I'm posting this here because the subject is med errors.

I have been LPN for 9 yrs. Worked LTC the1st two years and spent the last 7 working in drs office. I decided I needed a change and went back to LTC.Until now I have had a good nursing record. few errors, known for being concenious almost to the point of OCD. I thought I was a good nurse until recently.

In a 6 mo period I have made 1 insulin error, 4 doses not given errors all narcs.9A 9P, 9P not given,the last one was Procrit not given (hadn't came from pharmacy) for a pt with recent GI bleed, Coumadin ws held,ws having nosebleeds,nothing copious but still. I am now unemployed (resign or be fired). Thankfully none of the pts were harmed.

I am having a hard time finding LPN refresher courses in my area. Google said I should look at the hospital where I went to school, I was told they don't offer them. There is a nursing program at the local community college where I could take some classes but I need to learn quicker than a couple of times a week. I am reading everything I can get my hands on re med administration , documentation etc but I feel like I need something concrete to prove I can safely practice my profession.

I also need to work but am afraid to get another nursing job in light of the recent errors. I want to nurse but not being a danger to pts is my first priority.

Any ideas, suggestions , professional opinions are appreciated.

tommycher · Oct 28, 2004

I can totally relate. Nursing is such a huge responsibility. I work Tele, don't often have patients who go to OR, but had a lap appy I sent to surgery. I was so careful to do all the preparations. Added OR tubing to his IV tubing, did pre-op check list, etc. Then, he was down in surgery for an extremely long time, did not come back up on my shift. I had a dream that night that I forgot to prime the OR tubing, and he died from an embolism!!! Called the hospital the next morning and asked his nurse what time he had come back, and was all well? It was, just a long complicated surgery, ended up being an open appy. But, I could not get over how paranoid I could be!

tommycher · Oct 28, 2004

I can totally relate. Nursing is such a huge responsibility. I work Tele, don't often have patients who go to OR, but had a lap appy I sent to surgery. I was so careful to do all the preparations. Added OR tubing to his IV tubing, did pre-op check list, etc. Then, he was down in surgery for an extremely long time, did not come back up on my shift. I had a dream that night that I forgot to prime the OR tubing, and he died from an embolism!!! Called the hospital the next morning and asked his nurse what time he had come back, and was all well? It was, just a long complicated surgery, ended up being an open appy. But, I could not get over how paranoid I could be!

Bill Levinson · Oct 30, 2004

I have been an RN for 3yrs now. I believe it is unreasonable to be perfect, yet I am incredibly hard on myself for any mistakes I have ever made! I always reassure my co-workers that a mistake is a learning experience, but when it comes to myself I just can't accept that!

More than six times out of seven (based on the industrial 85:15 rule of thumb), your "mistake" is the fault of the system in which you work. Of the eight malpractice incidents discussed in detail on Oprah Winfrey's "Outrageous Medical Mistakes," only one would NOT have been prevented by a hospital quality management system that conforms to the international ISO 9000 standard. A doctor was haunted by a mistake that killed his patient but it was not him, it was the system in which he worked. (As an intern, he was required to perform without supervision a procedure that should have been supervised.)

Another example was the infamous case in which a patient was killed and two sets of transplant organs wasted because the first heart-lung set had the wrong blood type. It seems like a no-brainer to check the blood type and the surgeon (a man with a very good reputation) was blamed. Guess what; it was not the job of any specific individual to check the blood type match before the transplant. "It was Everybody's job, Anybody could have done it, Everybody assumed that Somebody had done it, but Nobody did it." In an ISO 9000-complaint system, there would be a checklist and someone-- a specific individual-- would have to verify the blood type match before the transplant could proceed. This is an example of how deficient quality managment systems (NOT careless or hurried doctors and nurses) cause about 85% of all malpractice.

The "learning experience" you describe should not be a personal learning experience for yourself but rather a learning experience for the SYSTEM in which you must work. In an industrial setting, a mistake (such as scrap or rework) would result in an investigation, not of WHO made the mistake but WHY the mistake was made. The system (procedures, equipment, materials, and so on) would be changed to prevent ANYONE from making that mistake again.

Or missing an important med because the staff making the MAR forgot to write the time the med was due.

This is a perfect example. The system should prevent the staff from forgetting to write the time the med is due. As an example, a computerized entry system could flag such omissions, and also check that meds were not spaced too closely by accident (e.g. someone types in 02:00 when they mean 03:00). This is known as error-proofing in industry. It prevents parts from being assembled the wrong way, selection of the wrong process recipe, and so on.

I have also advocated-- and this is now being done in some places-- having doctors enter their prescriptions into computerized systems as opposed to writing them by hand. First of all, this prevents mistakes due to unintelligible handwriting (reputed to kill 25,000 patients a year). It also allows the computer to check automatically for drug interactions and also obvious mistakes (like "100" when the doctor meant to enter "10"). Some hospitals are bar-coding medication containers to prevent errors as well.

Can anyone reassure me that I am progressing as expected, or does it sound like I need more fine tuning? Sorry so long!

Unfortunately, the things you describe are not going to change until hospitals provide doctors and nurses with quality systems that will prevent mistakes, errors, and omissions even when things get a bit hectic. I am working with a Pennsylvania legislator to encourage hospitals to implement quality management systems but they are simply not receptive (the PA Medical Society is not interested and the Politically Active Physicians Association told me where to go and what I could do when I got there).

Here is some more information on the proposed legislation:

http://www.pahouse.com/pr/Mundy/120031003.htm

Bill Levinson · Oct 30, 2004

You cannot imagine how glad I am that I found your message board. It is evident from the posts in this thread, especially yours and virmm1's, that deficient quality managment systems in hospitals are doing more than killing patients and driving up the costs of health care to the point where our entire national health care system is in danger. Deficient quality managment systems are damaging the morale and self-confidence of good nurses.

The last shift I worked, I made TWO mistakes. Both med errors.
I wrote down 159 instead of 129 for blood sugar after hearing the PCT say "159," and did not check to make sure it was that number. I gave 4 units reg insulin based on that.

Just from what you wrote here, I can tell you why this mistake happened-- and it had NOTHING to do with you or the other person. I can tell you how the Army would have done this (even though I have never been in the Army). The PCT would not have said "a hundred and fifty nine" but rather "one-five-niner." And before writing it down, you would have responded "one-five-niner," thus making it almost impossible to record 159 when the PCT really said 129. But the system in which you work did not have this procedure in place.

You may also wonder why they talk funny in war movies, spelling things out with phrases like "Mike Echo" instead of just saying "M" and "E." "M" sounds a lot like "N" and they can easily be confused-- but "Mike" cannot be confused with "November." The idea is to prevent things from being misheard or misinterpreted. Ah, here it is: the NATO Phonetic Alphabet

http://www.fact-index.com/n/na/nato_phonetic_alphabet_1.html

"The alphabet is used to spell out parts of a message or call signthat are critical or otherwise hard to recognize during voice communication. For instance the message "proceed to map grid DH98" could be transmitted as "proceed to map grid Delta-Hotel-Niner-Eight"... [noting that "D" sounds a lot like "T," you can appreciate the logic behind this]

I cried and my preceptor felt so sorry for me, he kept reassuring me all day that I was doing well. Whcih I knew came from feeling sorry for me rather than being proud of me.

I can tell you how I would have handled this (as a quality engineer). We would have done a Corrective Action Request or Quality Action Request to identify the root cause of the mistake-- namely that you misheard the number you were supposed to record. And the root cause seems to be that it is very easy for any human being to misunderstand a number, especially a number that is spoken quickly. The corrective action would have been to install a procedure, like the one I described above, so that no one could ever make that mistake again. Then there would be best practice deployment, which means looking for related activities in which the same kind of mistake could occur, and implementing the new procedure there as well.

I also, took from the PYXIS reglan and DHE and gave the reglan, but did not follow up with the DHE ten minutes later. It was 7pm, shift change, I was giving the med to a patient I was not giving report on (it was offically my preceptors patient, but I said I would give the med) so although I told my preceptor that I put the DHE in the patients med cart, I didn't tell the night nurse that information. She left a message on my machine which I didn't get until the next day saying she didn't know if I gave the med or not.

OK-- I'm not quite sure I understand the medical jargon (I'm an engineer) but it sure sounds like something that could be addressed by a good quality management system. Like a computerized tracking system that would verify when and if the patient got the DHE. This is done all the time in industry, to verify that "widgets" got a particular process. The bottom line, though, is that the blame for this is almost certainly in the system in which you work-- NOT with you.

It's nightmarish making mistakes. I can't stand it. The guilt is overwhelming and I don't know how to feel better about it.

And this comment is very important to me because it has taught me a new lesson. Deficient quality managment systems (and very few hospitals have good ones, the kind that are becoming more prevalent in industry) are doing more than harming patients and driving up the cost of health care. They are hurting the morale and confidence of health care practitioners.

nurstudnt546, BSN, RN · Oct 30, 2004

So glad I found this thread and at this time. I had my first med error today and I almost had a panic attack (gave the wrong dose of antihypertensive med - too high). I had a rush of emotions go through my body - GUILT, STUPIDITY, FEAR, SADNESS, ... I basically felt like I had killed someone. I'm still not over it and my eyes well-up just thinking about what I did. Fortunately the pt's BP do not bottom out. I am a perfectionist and did not think that this would happen to me so soon in my career (I'm still a student and am currently an intern).

I just wanted to post because I so feel your pain and am also having an extremely hard time forgiving myself.

Midwest4me · Oct 30, 2004

"I KNOW in my heart mistakes happen and it is a learning process, but you are both right; I am too hard on myself..." ..." I made a little motto for myself a few months ago: "Check if you're not sure, Ask if you don't know, Do the best you can!" We do the best we can.:)

You are indeed hard on yourself, but I can truly relate as I'm the same way. Therefore, I can't be too critical of you.:) (You evidently have a very caring heart.) By the way, I LOVE your "little motto". It's very good advice...and like you, I should follow it too! I'm glad to learn I'm not the only one out there who beats up herself over mistakes. It seems there are many of us.

I have to share with you what a friend of mine once said about himself: "I have failed my way to success." :rotfl: ...meaning, of course, we need to learn from our mistakes and hopefully not repeat the same one twice. His statement has been one of my all-time favorites.

Bill Levinson · Oct 30, 2004

So glad I found this thread and at this time. I had my first med error today and I almost had a panic attack (gave the wrong dose of antihypertensive med - too high).

Can you tell me how this happened? I will lay six to one odds that the basic problem is in the system in which you work. What I mean is that, if it is possible for you to administer the wrong dose, it is possible for anyone-- even a practitioner with 30 years of experience-- to make the same mistake. And if the hospital's quality management system is deficient, it is only a matter of time before that happens even if the staff consists entirely of nurses with 30 years of experience.

I just wanted to post because I so feel your pain and am also having an extremely hard time forgiving myself.

Most people in industry have gotten past the culture of blaming the worker when something goes wrong. It is the responsibility of management, with worker participation, to change the system to prevent mistakes from taking place. The incident you describe should result in the implementation of procedures to make it virtually impossible for anyone to make the same mistake in the future-- because, unless that happens, it is only a matter of time before the same thing happens again. And it doesn't matter how skilled or experienced the medical professionals are.

nurstudnt546, BSN, RN · Oct 30, 2004

Hi Bill L,

Well, I'm not one for making excuses but I believe the reason this incident happened was due a recent change in out computer systems. We recently changed from a "DOS-based" system to a "windows" type of system. Anyhow, the MARs that we now work off of are completely different from the old ones. I think the problem (and many other nurses do, as I am not the first one who has made this error) with the new MAR is that the first line of info displays the way the med to be administered comes (i.e. 200 mg tabs) and the second line shows the proper dosage to be given as ordered. So even though I did my "5 right checks" prior to administering the medication, I was doing my checks off of the first line instead of checking them off of the second line(hope I explained that clearly).

The following is a generic example of our new MAR:

colace 500mg / tab

colace 250mg / 0.5 tab

So I should have been checking against the second line where I was checking against the first line and the old MARs did not display such information. (i.e. in my mistake, I would have admin 500mg of Colace and should have admin 250mg)

The charge nurse that I notified spoke with pharmacy as I was not the first one who has made this mistake, so hopefully the changes will be strongly considered and implemented. Until then, I have to try and get over this (as I cannot blame anyone else but myself) and will definitely be doing everything possible to not make this mistake again for my patient's safety.

Bill Levinson · Oct 30, 2004

Hi Bill L,
Well, I'm not one for making excuses but I believe the reason this incident happened was due a recent change in out computer systems. We recently changed from a "DOS-based" system to a "windows" type of system. Anyhow, the MARs that we now work off of are completely different from the old ones.

The problem is definitely with the system in which you work, especially since others have made the same error.

In an ISO 9000-compliant workplace, the following procedure is followed whenever there is a change in the way the job is done. The work instruction for the job is updated. Everyone who does the job reviews the change and signs off that they have read and understood the change.

It sounds to me like the management team simply changed the system over without making sure that all nurses understood the new procedure. This would never happen in a hospital whose quality system met ISO 9000 requirements.

Also, as you describe the system below, it is very easy to see how someone can read the wrong information from the computer screen. From what I can see here, this display method is a disaster waiting to happen.* An instruction should never present two conflicting ways to do the job. If the two lines can be mixed up or misinterpreted, they will be.

I think the problem (and many other nurses do, as I am not the first one who has made this error) with the new MAR is that the first line of info displays the way the med to be administered comes (i.e. 200 mg tabs) and the second line shows the proper dosage to be given as ordered. So even though I did my "5 right checks" prior to administering the medication, I was doing my checks off of the first line instead of checking them off of the second line(hope I explained that clearly).
The following is a generic example of our new MAR:
colace 500mg / tab
colace 250mg / 0.5 tab
So I should have been checking against the second line where I was checking against the first line and the old MARs did not display such information. (i.e. in my mistake, I would have admin 500mg of Colace and should have admin 250mg)

There is something else I don't like about this-- the need to split a pill in half before administering it. That is admittedly a good way for patients to save money at home (e.g. the doctor prescribes 50 mg so you buy 100 mg pills and break them in half) but it might not be such a good idea in a hospital. Murphy's Law says that it is only a matter of time before a whole pill is administered when it should have been split in half.

Who splits the pills-- the pharmacist or the nurse? If they come from the pharmacy pre-split (according to the doctor's instructions for the individual patient) that might be all right but if the nurse has to remember to split whole pills, that sounds like a problem just waiting for a time and place to happen.

The charge nurse that I notified spoke with pharmacy as I was not the first one who has made this mistake, so hopefully the changes will be strongly considered and implemented. Until then, I have to try and get over this (as I cannot blame anyone else but myself) and will definitely be doing everything possible to not make this mistake again for my patient's safety.

You deserve credit (not blame) for bringing the problem to the charge nurse's attention. This will hopefully result in changes in the system to prevent future medication errors that could easily have more serious consequences. The changes you initiated may, in fact, save someone's life some day.

* Disclaimer; I cannot provide official consulting advice over the Internet and these observations are based only on what I can see from here.