Made it through three night shifts on my own...then...

Double-Helix, BSN, RN · Aug 22, 2012

We all make mistakes. This will certainly not be the last one that you make. No one expects you to be perfect- and you can't expect it of yourself. What matters is that you learn from your mistakes and identify ways to prevent them from happening again.

Several months ago I discovered that my patient (also in pediatric ICU) had the wrong bag of fluids hanging. In this case, it was a much more serious error than hanging NS vs D5W. It was a specially prepared bag of fluids for a patient in DKA that had a specific concentration of electrolytes. The bag was labeled by the pharmacy for the correct patient, but had been hung on the wrong patient- who should have been receiving plain D5 0.45%NS. The nurse who hung the wrong fluids was by no means a new nurse- she had worked on the unit for nearly 20 years.

I share that story to illustrate that even experienced nurses can make the same mistakes as a new nurse. It doesn't matter if you've already "gotten it" or if you've got years of experience and can handle the sickest patients on the floor. We are human. It sounds like you're doing great in your new job. In a year, or even in six months, you'll look back on how you feel at this moment and be amazed at how far you have come. Hang in there. You'll make it. :hug:

JZ_RN · Aug 23, 2012

Is the patient okay? If so, lesson learned, no harm done. Just always double check from now on. Stuff happens. Good luck.

Been there,done that, ASN, RN · Aug 23, 2012

An easy mistake , unless you are required to scan fluids. I would assume on a pediatric BMT unit that would be a requirement, all meds and IV's are scanned. Am I wrong in that assumption? If not they should be. Perhaps that is what you could add to your write-up response as to how you can improve.

What did you orientation consist of? A BMT peds unit would be VERY difficult for a new grad. I hope you got a VERY thorough orientation.

If it's any consolation, the first time I realized I had hung the wrong solution, it was with ten years of experience, and the patient was a doctor! During my triple check, I realized I had hung the wrong solution.. and tried (very suavely) to explain why I was going to get another bag:)

Kudos to you, it's a tough area to learn on.. I am certain you won't repeat that mistake.

hiddencatRN, BSN, RN · Aug 23, 2012

An easy mistake , unless you are required to scan fluids. I would assume on a pediatric BMT unit that would be a requirement, all meds and IV's are scanned. Am I wrong in that assumption?

Not all hospitals scan meds or fluids.

To the OP: I've seen that happen at work too, and while I haven't personally hung incorrect fluids, I've made my share of other errors.

LaRoseRN · Aug 23, 2012

No harm done to the patient. The fluids on our unit are not scanned - we don't scan any of our meds. Our orientation was over five and a half months, but it is still extremely overwhelming. I am still not sure how I missed this, honestly, since I had this patient three nights in a row and was very familiar with his care. I am new to night shift and I've realized that three nights in a row isn't good for me -- too much anxiety + sleep deprivation by the third night.

I will certainly be quadruple checking from now on...

Lesson learned.

Thanks everyone!

CrunchyMama, ASN, RN · Aug 23, 2012

I assure you, that won't be your last mistake. You're going to make minor ones and hopefully nothing will hurt or kill anyone. I graduated a year ago and have been working ever since and I still feel like an idiot, lol....not as much as a year ago, but still do. I've learned not to get upset by the mistakes, you truly learn from them....so in a way they're a good thing. Things get better. Good luck!

apocatastasis · Aug 23, 2012

Agreed with all the above. You will make many mistakes, and you will catch yourself just before making many more. I'm sure you feel bad, but even though this seems like a big deal now, in a couple of months it will not be on your radar.

I've cared for thousands of patients by now in ICU and ER, and made my fair share of errors. No one has ever died or been harmed, but with some of the errors, they definitely could have been.

Double check your orders.

Do the six rights three times. If it's a really high risk fluid or med, do it a fourth.

Double check your tubing and pump settings regularly.

Lastly, a trick that I use: when I take down an old bag and replace it, I compare both old and new bags to make sure it's the same fluid/med and the same concentration. I have prevented or discovered probably a couple dozen med errors this way, sometimes my fault and sometimes not.

PunkBenRN · Aug 23, 2012

If thats the worst thing thats happened to you tonight, you're in good shape

Indy, LPN, LVN · Aug 23, 2012

When I was new, I had this wiggly, demented ole feller on a dopamine drip. It was a renal dose so there was a 250ml bag of NS hung for KVO. No problem. The dopamine bag was also 250 ml. The pump alarmed, a bag was empty, (no we did not have scanning or such at the time) I said "oh my dopamine's out" and went and got some.

I stopped the pump, stood there with a bag in hand, unspiked it, opened the new one, and the patient moved or something, while I was busy thinking about the pump that the line ran to and how the rate just sounded "off" for dopamine, causing me to drop the full, open bag of dopamine and spill it on his bed. Then I realized it was the NS that was out. Pharmacy was very nice when I explained that I hadn't hung it, but was gonna, could they not charge it to the patient please, it's wasted in the linen.

I felt so bad that I nearly cried; but hey, the patient got a bath, he didn't get triple his dose of med, he never knew, honestly, that anything was wrong. And I got this new habit of triple-checking just when I'm about to hang something. It's no wonder we're OCD as all heck- we develop these habits before and after we make mistakes. Relax. You did something wrong, and you learned, and it won't be the last time.

AZMOMO2 · Aug 23, 2012

The important thing is you took responsibility for your mistake, you will remember next time and every time after that to triple check and then some. Most importantly give yourself a break. Real life nursing has a HUGE learning curve and you know, one of these days you will be just like those seasoned nurses, who by the way, were in your shoes once too!

SwansonRN · Aug 23, 2012

I'm also a new grad in the first month on my ICU orientation. I made the exact same mistake! I almost bolused my patient with the wrong IVF. Just as I pressed run on the pump I noticed D5 was hanging instead of NS. I stopped it right away and panicked/beat myself up over it all day. I never realized how EASY it is to make a mistake. Definitely a learning experience.