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Discussion

Made a mistake during orientation

Hey everyone! I'm on my second week of orientation as a RN on a telemetry unit. Before this job I worked as a med-surg nurse for 2 years. I did take a year off from working as a nurse before this new job due to personal health issues, which are much better now! It was my second shift caring for an elderly patient admitted with a bad case of epididymitis. He had a history of several urology conditions, including BPH and urinary retention. He was taking medication for these conditions too. He had been in the hospital for a week before I took care of him and the scrotal swelling had not improved. We were icing and elevating his scrotum and giving him IV ABX plus normal saline at 100 ml/hr.

On my first shift taking care of him, the urologist discontinued the IV fluids at 10 am. I did not see this order and the fluids continued to infuse. I was still getting use to the charting system at the hospital and I did not know that when a medication order goes from black to grey it means the order is discontinued. My preceptor had missed the order too. At this hospital we do not scan bags of normal saline, we just document the infusions in the I & O section. I reported off to night shift, who also missed the discontinued order.

I returned the next day and resumed care for the patient. Normal saline was still infusing. Pt was reporting straining with urination, which was not new for him. And I bladder scanned him at the start of my shift and only 130 ml of urine were present. There were no orders to straight cath or start a foley and I made a mental note to bladder scan the patient again in a few hours. And I never did. At 5 pm that shift the urologist came to the unit to evaluate the patient for discharge. He asked why the urine output was so low and why the patient was still receiving IV fluids that were discontinued 30 hours ago.

The urologist bladder scanned the patient and more than 1000 ml of urine was in the bladder. He turned off the IV pump himself and inserted a foley cath in the patient. And the patient ended up having to stay in the hospital instead of being discharged home. The patient had received an extra 3L of fluid that he should not have gotten and certainly contributed to the urinary retention issue. I feel like such an idiot for missing the order, which complicated the patient's stay in the hospital. I filed an incident report and was promptly called into the nursing manager's office. I was suspended from work today and told to take the weekend to come up with a course of action on how to improve my performance for the rest of orientation.

It has been rough transitioning back to bedside nursing after taking a year off. The new grad version of me would have never made a mistake like that. And this experience was a huge eye opener. I feel so ashamed that my negligence harmed a patient and I want to resign before I am fired. Two other nurses had missed the order change too, including my preceptor that has been a nurse for 30 years. So I feel that all the blame should not be placed on me, but I do take responsibility for my actions. Am I being too hard on myself or are some mistakes unforgivable? Any advice would be greatly appreciated. Thank you

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    I'm sorry you are going through this! It is a very tough situation. First, everything will be okay. Take a deep breath. You are a new nurse. You made a mistake. The reality is that mistakes happen. The patient is doing well now and even though you missed an order, you kept the patient safe.

    From my perspective, you understand what you did wrong and know you have room to improve. You have reflected on the situation. You messed up and you are taking accountability. But, you are correct in stating that you are not the only person to blame! First, you are a new nurse and your preceptor is supposed to oversee you. She should have caught the mistake. The nurses who came after you also should have caught the mistake and they didn't! It also seems like your computer charting system is not clearly identifying when an IV fluid is discontinued. Also you are not scanning the fluid which automatically adds input to the Is and Os. If you could have done either of those things this problem could have been avoided. This is a systems issue that you should bring up with your manager.

    If you meet with your manager stay calm. Keep your head up. Of course you will explain that you take accountability for your actions. But if your manager is fair you will not be fired! If they look into this further they will realize there were multiple people and systems at fault.

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    On ‎7‎/‎23‎/‎2020 at 2:49 PM, surfnurse90 said:

    Sorry - I can't get that upper entry to delete somehow. Not intended.

    As ajnurse2b6 commented, this was a MAJOR systems error issue just waiting to EXPLODE & FAIL.

    For your part, you need to focus on YOUR role in the error. Identify YOUR specific weaknesses and how to remedy them. I see several areas to work on. Sadly, the error started with you and snowballed after that.

    Be SUPER DUPER careful how you address that other nurses also bear responsibility in the error; also that pharmacy fail-safe measures are lacking.

    If your Admin/mgt is fair and understanding this will become a learning opp'ty for all. I suspect that you will experience some negative feedback re this episode.

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    It sounds like this is the “Swiss Cheese Model”. It went past multiple nurses.....you, your preceptor, the night shift nurse, etc. I also find it odd that your tele floor doesn’t have an electronic MAR scanning system. These systems aren’t full proof by any length but they do often offer prompts that may show when a med is overdue, not due, not ordered, etc. It sounds like you recognize your part - but remember that many people played a role in this, not just you.

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    Any update @surfnurse90?

    Were you able to return after the weekend to present your plan and discuss this with your manager?

    This is certainly not an "unforgivable" mistake. I hope you were not terminated and did not decide to resign either.

    It sounds as though there is not a solid process for checking new orders, and also there is definitely not a good process for hanging NS. One tip related to your story is that of recognizing an unsafe process before something happens and doing what you can to make it safer. In this example, the IV NS is not scanned for some reason. As a nurse, you recognize that hanging IV fluids still requires the 5Rs whether the med is scanned or not. So then you put it into your own personal process to conscientiously complete the 5Rs even with a bag of saline that is not going to be scanned.

    I'm really sorry this happened. You are not solely at fault. Your disgust with yourself is understandable and at the same time unfair. You know what went wrong, learn from it and move forward.

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