Made a mistake, need advice

Nurses General Nursing

Published

Specializes in Home health.

Hello all,

I am a nurse, seven years experience here. I am needing some advice as to how to mentally get past a mistake at work. Here is what happened. I work in home health, and was taking care of a patient with a catheter which is new for the patient and home health was ordered to teach catheter care. The patients urine output is bloody and when the previous nurse was with the patient, they noticed very little urine output and they irrigated the catheter and then it started to flow. They also showed the caregiver how to irrigate as well in case they needed to do so. So fast forward to the next day, I have this patient on my assignment and I am to go in and reinforce the irrigation procedure. Previous nurse gave me report and said that they taught the patient how to irrigate using the little blue leur-lok access area on the drainage tube and used a piston syringe with the little blue leur-lok removable access device tip that just pushes into the leur-lok. So I said okay I will reinforce that. I get into the home and what I am looking at is NOT what I thought I was going to find. I thought I was going to find a piston syringe with the grooves on the end that actually TWISTS into the leur-lok (like a NS flush twists into an IV), but instead found a regular piston syringe with the blue cap that pushes straight in. I have never irrigated this way before, always have just disconnected the catheter from the drainage tubing and irrigated that way, and I had a momentary brain fart and told the caregiver that the piston syringe is placed into the BALOON PORT to irrigate. Now I did not actually irrigate while in the home because the urine was flowing out well so it wasn’t needed, but I SHOWED the caregiver how to irrigate it step by step. Fast forward about two hours and I’m at the office charting and it hit me that I had told the caregiver to irrigate in the wrong port. I immediately called them and told them the correct way to irrigate and actually went back out to the house and made sure I showed them the correct way and that they understood. I told my charge nurse. And most importantly, he didn’t have to irrigate in those two hours and the patient was not harmed.

Now, granted I’ve never irrigated a Foley this way before, but I have inserted PLENTY of catheters. I just can’t mentally get past the fact that I would even consider doing what I told them to do. It scares me that I didn’t think of it until two hours later. I KNOW that port is for the balloon inflation, I’m just having a hard time mentally getting past this. I have never really made a mistake (not to my knowledge at least) like this. Any advice on how to cope with this would be greatly appreciated! Thanks!

1 Votes
Specializes in Travel, Home Health, Med-Surg.

I wouldnt worry about it too much, we all make mistakes, and chances are in the last 7 years you have made some already. We are human so of course mistakes will be made. You did the right thing when you realized it and no harm done. If you are afraid of making mistakes in the future you could make note card (or something like that) for procedures and review it first (I had a procedure book when I did HH). Also, I would take what the former nurse says with a grain of salt bc they are also human and make mistakes. These things happen, learn from the mistakes, let it go, and move forward with now increased knowledge. Also, did that nurse just irrigate and not let the MD know, and you also need a order for that (which maybe you already had).

1 Votes
Specializes in Home health.
19 minutes ago, Daisy4RN said:

I wouldnt worry about it too much, we all make mistakes, and chances are in the last 7 years you have made some already. We are human so of course mistakes will be made. You did the right thing when you realized it and no harm done. If you are afraid of making mistakes in the future you could make note card (or something like that) for procedures and review it first (I had a procedure book when I did HH). Also, I would take what the former nurse says with a grain of salt bc they are also human and make mistakes. These things happen, learn from the mistakes, let it go, and move forward with now increased knowledge. Also, did that nurse just irrigate and not let the MD know, and you also need a order for that (which maybe you already had).

Thanks so much for your response. It made me feel better. That’s a really good idea to carry a procedure book. Do you have any suggestions on good ones to carry and where I can purchase them? And yes we did have order from MD to irrigate. Thanks again!

2 Votes
Specializes in Dialysis.

Shake it off! You've corrected the mistake, both with yourself and the client

2 Votes
Specializes in Travel, Home Health, Med-Surg.

I am sorry but I dont really have any recommendations for a book as it was about 15yrs ago when I had it. I do remember it was published by one of the companies that also published the books we used in school, like Mosbys or something like that.. Maybe someone else might? Or maybe you could find some resources online or from your coworkers.

1 Votes

Mosby’s Pocket Guide to Nursing Skills & Procedures, 9th Edition is available in both print and Kindle version on Amazon.

https://www.amazon.com/Mosbys-Pocket-Nursing-Skills-Procedures/dp/0323529100/ref=dp_ob_title_bk

4 Votes
Specializes in Travel, Home Health, Med-Surg.
21 minutes ago, chare said:

Mosby’s Pocket Guide to Nursing Skills & Procedures, 9th Edition is available in both print and Kindle version on Amazon.

https://www.amazon.com/Mosbys-Pocket-Nursing-Skills-Procedures/dp/0323529100/ref=dp_ob_title_bk

Well there you have it?

1 Votes
Specializes in Home health.
42 minutes ago, chare said:

Mosby’s Pocket Guide to Nursing Skills & Procedures, 9th Edition is available in both print and Kindle version on Amazon.

https://www.amazon.com/Mosbys-Pocket-Nursing-Skills-Procedures/dp/0323529100/ref=dp_ob_title_bk

Thanks so much! ???

1 Votes
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