I have been a nurse for 7 years and only one med error done within my first week of being a nurse. Well after two days ago..that has changed, and let me tell you...it hurts! However, since I am a believer in sharing stories like this to help others not make the same mistake...let me share this with you so you don't do what I did!
It was a crazy night, I was floated to a floor and wound up with 6 pts. Two were total admits from MD offices (TONs of paperwork and stablization), two discharges, one using translator phone (long d/c), then one fresh post op that had out of control pain and nausea/vomiting, and one old lady who loved being pampered and was on the call light every 5 minutes or so. Needless to say I was going nuts...no CNA, no help!
Then...after 4 hours I was floated to another floor....yeah right after I got it all done in a rush and everyone was sleeping..grrrrrr! I went to the next floor and got 6 whole new pts! No breaks, tired, and not happy about this! Three post ops, one gal who was suffering an infection and was pregnant, and another very quiet pt. All was crazy with med passes~! Heck, even through three folks were on PCA's I still had back up pain meds every 1-2 hours, and they were all using them! It was a nightmare and wound up finishing my 2000 meds at 2300!!!!!!! I needed help, but couldn't even tell anyone where I needed it because I was so flustered...not like me at all!!!!!!!
So towards end of shift, I wound up giving some Dilaudid in one gals PCA...and stupidly I also gave another Dilaudid into anothers PCA who was supose to get morphine! Okay...for those that don't know...Morphine is regulated in mg, Dilaudid in POINT something mgs! Big difference! I left and didn't even realize I did it!
It was caught early thank goodness, oh and yes...it was the pregnant girl I did it too. When I found out I was instantly in tears asking about the gal and baby. They were fine but very angry...which I would be too. I expected to be fired...but was not.
Since this was a workload and management issue in scheduling as well as my error...I was not fired, but will help them come up with ways to avoid this from happening again! I will work on a plan, including how loud those PCA machines are when they are empty (frazzles an already frazzled mind, and upsets pts!), and how to clearly mark the different syringes (although I totally just goofed...I thought it was Dilaudid so even a difference in syringes wouldn't have helped....uhggggg!).
I think about the damage done, not physically to the Pt..but emotionally! My managers said "she is fine" and I said "nope, damage to her emotions, trust, and perhaps spirit was done because of my stupidity...that is a longer lasting thing to bear for pts and myself".
Please, if your loads are too much...stop, and tell your charge nurse and seek out help! If I had just taken the time to talk to my charge nurse and explain things...all could have been avoided by me rushing around doing things half way or not at all. That is NOT ME at all!
And here's hoping I still have another 7 years before my next mistake...LOL!
Specializes in Education, Acute, Med/Surg, Tele, etc.
Oh not a probelm at all!!!!!!!! I will answer these no probelm!!! :)
"I do have 2 questions though.. you mention that "if it wasn't me, it could've been worse..." I'm just wondering what you (or your co-workers) meant by that. The error was the error, no matter who made it. How could a different person making the same error turn out to be a worse outcome? Or did they mean that a possibly DIFFERENT, worse, error could have been made if it were a different nurse? I guess I'm confused by that.
The other question is why are you saying that you actually gave the patient a safer med for her? Her physician is the one who makes that call- I'm confused about whether or not that physician is the one who told you that you had given her a safer med, or are you just extrapolating? "
First question. My charge nurse said this to me, and I will admit that this could have been a probelm. I am the only nurse with experience on this floor at this particular moment, all the others are new grads and this would totally be wrong to do to them (let alone me). She was giving me a supportive compliment in her way...but yes, I will admit that if a new grad had this load, it could have been different due to even more stress and confusion by being new (I had all 6 pts fresh post ops with PCA's! Thank Goodness I didn't screw up the other 5!)! Thank GOD they didn't do that to a new grad..the would have been screaming and running out the door, and I would have held the door open with a hug for them! It shouldn't have happened anyway...but, I should have been more careful and followed my instincts on double checks instead of letting myself get flustered. No offence towards new grads, but holly cow if I had a probelm...can you imagine being BRAND NEW to the hospital and nursing!!!!!!! I am glad it was me and not any one of those wonderful grads! They don't need that stress!
Second, the MD said that actually Dilaudid was a safer medication than morphine for the baby. Quicker half life, and actually fulfilled the pts pain complaints. I don't know why they didn't switch it over in this case...maybe the pt wanted morphine or a lesson was being taught. All I know is that it did help the pt, was not harmful thank GOD, that I made a huge error, and it was corrected.
Hope that answers your questions :)...I am very good at constructive critism, and thoughts on how to better this situation for not just me but others and pts is always a good thing!
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
thanks for sharing. it just goes to show that anyone can make a mistake -- and one of the lessons to take away is that making a mistake is understandable; covering one up is not. i've seen more than one nurse make a mistake, lie about it, and even enlist others to help cover it up. kudoes to you for being open and honest!
our institution requires a double check and cosign of pain orders and pca programming with another rn each time we change the programming or the syringe. it's painfully difficult sometimes to find another nurse, but might have prevented this error.
anyone who says they have never made a med error is either lying or just doesn't know they made it . . . maybe we should start a thread on med errors. it might help prevent someone else from making any of the same mistakes!
Specializes in Education, Acute, Med/Surg, Tele, etc.
Oh Ruby Vee...I was ready to be fired and I was honestly thinking it was a totally just thing! I guess I was raised to believe that if you make a mistake, you deal with it and its consequences...never cover up..that will wind up with more trouble.
I just got an e-mail from admin today saying they appreciated the fact that I was honest, and fessed up immediately with no contest! That I was heartfelt in my appology, and wanted to make a change for the better for not just me...but others! I guess that is rare, because they didn't know really if I was being sarcastic? They were like "OMG she is being really honest!!!!!!!!!!!!). That in itself is sad!
I am no different from other nurses here and beyond...at one point you fear getting your license taken....then you move on to accepting your mistakes...human or not...and making it beyond it. I have, and had the opportunity to do so (some don't!)....I am just thankful I chose work in a facility that really has some sanity about their nurses and their rolls...as stressful as they are.
My hope is that no one reading this will make that error becuase frankly...it hurt me so very much! Touched on each emotion and could have easily swallowed me whole. But experience has taught me that I can go on...and learn from it! That took years! And others can most certainly do it too! Don't let it get you too down...don't think of the 'what ifs' (if I thought of those I would have been a psych! HOnest!)...and just do better, and keep being helpful to others so that mistake is lessened by just talking about it!
Well, I have to say, this forum is a blessing. I'm learning in advance to think about things I will and will not do. I will lose my job before I will float to two floors in one night. That's ridiculous. No nurse should be expected to be able to acclimate to such a number a patients with such varying dxs. Nope. I'll be wearing the blue vest at Wal-mart before I do that.
there's no way anyone could cover up an error like that if they wanted to, and I don't know why anyone would want to, the syringe was signed out and hung by one nurse after all
good thing your administration was supportive and didn't berate you for it :wink2:
Not an area I would usually post, but I have a few comments:
First: Kudos to you. Upon finding themselves in the position you were in, many would scramble to throw off as much blame as possible. You didn't. You took responsibility for your own actions, regardless of the outcome. That alone speaks volumes about your character.
Second: Kudos to your hospital for their (apparent) recognition that the error was caused by a systemic problem. More than a few hospitals would refuse to acknowledge that they set the nurse up, finding it easier to hang the nurse out to dry.
Third: While accepting your responsibility in this, please be sure to see that there is more than enough blame to go around. You were floated twice in one shift. After cleaning up a mess in one unit, you were promptly sent to another unit. The units to which you were floated dumped on you twice in one shift. After cleaning up one mess, another unit dumped an entirely different mess on you. I think if you will check your Funk and Wagnall's, this situation neatly meets the definition for a number of things, none of them positive.
I have always been against floating nurses, particularly to areas with which they are unfamiliar. It's a dangerous practice. To float to two different units in one shift is abusive beyond the pale. As a staff nurse, I always had certain rules about how I would float, and would not allow those rules to be violated.
-When floating to a different unit, I took no more than four patients. I was an ICU nurse, and my time management skills were geared towards caring for two patients. Even if you are a med surg nurse, accustomed to caring for more than two patients, remember that you are in an unfamiliar area, and may be giving meds you are unfamiliar with. You have no more knowledge of that floor than a new orientee, and therefore to expect you to take the patient load of a nurse experienced on that floor is unreasonable. When I arrived on such a floor, I would tell the charge nurse about this. Only once did I hear a complaint, whereupon I immediately offered to not take report, return to my unit, and they could do without me taking four of their patients. She shut up.
-If I floated to a unit that treated me in an unprofessional or abusive (and giving a float nurse the "problem" assignment is abusive) manner, I documented it and discussed it with my unit manager. If it occured twice on a given unit, I refused to return, and had written documentation to back up my refusal. (There was actually one floor that this happened with, and I never returned. Even when they were short and it was my turn to float.)
-I never floated to areas or took assignments that I knew were beyond my abilities. As an adult ICU nurse, I felt pretty comfortable floating to the peds ICU and taking two patients. I felt far less comfortable floating to the NICU, and would only take a one patient assignment, and then only with a resource nurse VERY close by. OB was beyond my ken, and I only floated there once, and only to act as what was essentially a nurses aide.
In short, while I know you feel like crap, remember that you were handed a stick that shift. And the end of the stick you were handed wasn't exactly clean. Taking responsibility for your actions is commendable. But remember, you don't really even bear 50% of the responsibility for what happened.
Specializes in vascular, med surg, home health , rehab,.
Great post, brave of you to share it. I think we all (or shall I say those who care) get "supernurse" syndrome when facing ridiculous workloads. Good god, what a frigging nightmare. A case of moving nurses like chess players. So glad your pt is ok ans that your facility backed you up. No-one could handle that and without being lucky keep up and not make an error. Absoultely good advice re speaking or screaming if need be. Or else you become the hamster running like hell on that wheel, getting nowhere except fried. The more you tolerate the more gets dumped on you. Learning this myself, just thank my lucky stars not to have had the same experience (that I know of anyway). Please don't beat yourself up over it, you just found out your only human, doing the best they can with bad odds. But for the grace of God go I right?
I have just a year of experience, but I'm a good, efficient nurse. My heart just skipped a beat when I read your assignment! I could NEVER have done that. I'm sorry you even had to try -- sounds like you did a great job, all things considering.
RN007
541 Posts
thank you so much for sharing. i'm in my next to last semester and will keep your story with me.
i hope you feel peace soon ...
(((((hugs to you)))))
linda