Learning from my mistakes

[dorselm]

Recently I made some very stupid mistakes. I had a patient who was admitted for hypoglycemia. When he came to our floor his blood glucose level was 94. Later he was ordered 30units of lantus. I was supposed to scan the patient, scan the meds and then give the meds. Instead, I scanned the patient, and skipped a step and gave the meds. I inadvertently gave 30of humalog instead of lantus. When I went to scan the med immediately it came up humalog and my heart dropped!!!!! I instantly got terrified because a patient on my watch a few weeks ago got out of bed and broke her hip.

I checked the patient three times but neither me or the nurse checked the bed alarm. The next day I told the nurse practitioner expecting him to call the family but neither he or the daylight nurse called the family and the family was livid that no one was notified. I didn't get reprimanded for this at all. But then this blood sugar incident happened. After I panicked I tried to correct the blood sugar by giving him lots of sweetened juice but of course it didn't bring his blood sugar up fast enough. His blood sugar went to 30 and he felt a little dizzy but never loss consciousness. I kept thinking "just scan the lantus and say he went hypo because of it" but I couldn't bring myself to lie. An hour later, I told the residents who were on the floor and they told me to get d50 which I did and his glucose level came up. But it kept going up and down because the humalog was still working. The daylight crew came on and I stayed until the patient was stable. When I left his glucose was 108 and he felt better but the doctors were livid.

Not only did this happen but the night before the blood sugar incident I had a female patient come in for elevated blood pressures. She was in the 190's and very symptomatic. She had severe headaches, vomiting and rigors. She was ordered to have a stress test. The doctors who ordered her stress test also ordered for her to have a beta blocker. There are standard orders not to give beta blocker with thin 24hrs of a patient going for a stress test. I completely forgot the order or that she was going for the test. My priority was to bring down her blood pressure to alleviate her symptoms. She had betablocker and lisinopril ordered that the doctors ordered. When they found out I gave the betablocker, they were upset with me. The next day the stress test was cancelled and the patient ended up being cathedral and stunted. But this betablocker issue and the blood pressure issue led to me being suspended. My co workers don't feel that I should have been suspended but take full responsibility for it however the blood pressure incident is where I don't think they should count that against me. I deserved what I got and after being a nurse for 5 yrs I should have known better. I could have lied and easily covered it up but I told the truth. I'm scared that I'm going to be fired. Being the main provider for my family and so close to Christmas I am soooo scared but I definitely learned a good lesson. I just needed to get this off of my chest I feel humiliated and ashamed. I will respect any comments that come my way.

[nurseprnRN, BSN, RN]

That's a lot of really serious lapses in a pretty short period of time. Each involves what some might call a wanton disregard for policy, terrible lapses in judgment, inability to use critical thinking skills, and disorganization. A very bad cocktail.

Why do you think you have been committing these serious errors lately?

[sallyrnrrt, ADN, RN]

cuddos, re doing the correct thing related to the insulin......

ok we get busy and distracted, ALWAYS do the six + checks with meds,

not just right med, right dose, route and right patient, incorporate RIGHT RATIONALE

the right rationale, may have helped you with the beta blocker, stress test incident...

always turn each mistake into a positive learning experience

[dorselm]

That's a lot of really serious lapses in a pretty short period of time. Each involves what some might call a wanton disregard for policy, terrible lapses in judgment, inability to use critical thinking skills, and disorganization. A very bad cocktail.

Why do you think you have been committing these serious errors lately?

I had 5 patients to care for the night I gave the betablocker. I was doing q1hr pressures on her and Q1hr blood sugars on another patient and straight catching a patient and I was charge nurse. The night of the blood sugar incident there was no excuse.

[dorselm]

cuddos, re doing the correct thing related to the insulin......

ok we get busy and distracted, ALWAYS do the six + checks with meds,

not just right med, right dose, route and right patient, incorporate RIGHT RATIONALE

the right rationale, may have helped you with the beta blocker, stress test incident...

always turn each mistake into a positive learning experience

Absolutely Sally I will do just what you said thanks for the feedback.

[SwansonRN]

It's seems like you were a little lackadaisical with passing meds. Even with a scanning system you should be using your 5 rights every time. I also always take a second to ask, "is there any reason I shouldn't give this med?" Once you give a med, you can't take it back.

Do you work nights? What do you think is the common link between these mishaps?

[blondy2061h, MSN, RN]

Everyone makes mistakes. The more serious issue I'm wondering about is why you waited an hour after giving someone who was already hypoglycemic a huge mistaken insulin dose before notifying the providers, and even then doing it as almost an after thought because you saw them? Also, that it even crossed your mind to falsify documentation to cover this up is deeply concerning to me. We all make mistakes. It's what we do after them that shows our character and helps minimize the fall out from these mistakes. I do hope your streak ends soon. Hospitals are cutting corners left and right to save money. They're cutting in terrible places and it's harming patients. It sounds like you and your patients may be victims of this.

[dorselm]

Everyone makes mistakes. The more serious issue I'm wondering about is why you waited an hour after giving someone who was already hypoglycemic a huge mistaken insulin dose before notifying the providers and even then doing it as almost an after thought because you saw them? Also, that it even crossed your mind to falsify documentation to cover this up is deeply concerning to me. We all make mistakes. It's what we do after them that shows our character and helps minimize the fall out from these mistakes. I do hope your streak ends soon. Hospitals are cutting corners left and right to save money. They're cutting in terrible places and it's harming patients. It sounds like you and your patients may be victims of this.[/quote']

There are sooooo many people who say nothing everyday and night when they make mistakes on my unit. Can I prove it? No but when I see some of the inept things that go on I know there are plenty of mistakes that happen. No one but me owns up to them. I am human and when you're faced with a crucial situation all sorts of things run through your head. I couldn't bring myself to lie which is why I pulled myself together, went into the room and told the doctors so the patient could get the proper care he needed concerning the blood sugar incident. I work on a 23 bed unit. At night there are 3 nurses and 1-2 aides. So each of us nurses have 7-8 pts on a med-surg floor and I am almost always charge nurse. In addition to caring for patients I have to prepare a report for the next charge nurse, do nurse and aide assignments, attend a meeting, keep tack of our census and downsize if needed or try to staff if someone calls off. It's a lot and sometimes overwhelming.

[nichefinder]

question as relatively new nurse, so when sbp is >190 and pt is very symptomatic, did the doctor still give you orders for betablockers WHILE they KNEW that the pt couldn't get the bp med anyways?

anyways, still what was use of maintaining pt on such high bp for such a longtime just so they can do stress test? i can yell out "stroke city" in this case, and probably prioritize lowering bp and communicating that to the physician my priority, so i don't think your judgement in that case was incompetent. well, incorrect med admin for short cutting steps... can't cover you on that though. but i could make mistake like that one day in my career when balls drop to the floor, so no harsh words here. hope you recover well though!

[dorselm]

Yup the doctor ordered the stress test and the bb but I got yelled at for giving it. Thanks for the comment.

[applewhitern, BSN, RN]

Regarding the insulin, we have to have two nurses verify the insulin and the dose before we give it. This cuts down on errors. The second nurse has to sign in the computer that they witnessed it, and that it was correct. If your facility doesn't do this, maybe they should.

[CrossCountryRN2008]

There are sooooo many people who say nothing everyday and night when they make mistakes on my unit. Can I prove it? No but when I see some of the inept things that go on I know there are plenty of mistakes that happen. No one but me owns up to them. I am human and when you're faced with a crucial situation all sorts of things run through your head. I couldn't bring myself to lie which is why I pulled myself together, went into the room and told the doctors so the patient could get the proper care he needed concerning the blood sugar incident. I work on a 23 bed unit. At night there are 3 nurses and 1-2 aides. So each of us nurses have 7-8 pts on a med-surg floor and I am almost always charge nurse. In addition to caring for patients I have to prepare a report for the next charge nurse, do nurse and aide assignments, attend a meeting, keep tack of our census and downsize if needed or try to staff if someone calls off. It's a lot and sometimes overwhelming.

There should be 4 nurses for that many. Three for the floor and a charge