major error in NICU

Nurses Safety

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I am totally down in the dumps. I have been an RN in pediatrics for almost nine years now. I have been working in NICU since last April. I made my first error the other night and I am on the verge of getting out of nursing or a major depression. maybe both. I reset an IV for a coworker (who has 25 years NICU experience). I was only going to put 50 ml in the buretrol b/c that is what I normally do for safety. I had the pump correctly set at that point. She asked me to put a hundred and was standing next to me. I accidently put 100 as the rate insead of 13.7. This was D17 TPN. The baby had about a 45 ml bolus before she caught it. He was very shaky and the glucose went sky high and then bottomed out but finally leveled out. He was already having glucose instability and very sick with meningitis. The NNP responded and tried to comfort me. I did the incident report and took full responsibility even though other nurse was standing there with me since I set the pump. The only blessing is that this was a term baby rather than a 600 gram preterm. In that case the baby might have died. I can't stop crying. I haven't heard anything from my boss yet, but I am sure the story is all over the unit. I was caring for the three intensive babies and so was my coworker. Staffing is not safe when our census is up, however I still messed up. I am wondering how to get over this or should I just find another job.

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im so sorry! (hugs)

wait you were caring for 3 NICU babies by yourself? Im a nursing student but I thought that it was 1:1 or maybe 1:2 at the most...at least in adult ICU thats what it is. If im right, then thats totally unsafe work environment and id leave there asap

hopefully it all works out for you

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The baby lived, and you will remember this for the rest of your life and the best thing is you will LEARN from it! You said yourself its a good thing it was a full term baby. This was your moment of "holy COW!" and now you know to be extra careful. Everybody messes up, be thankful for the mess ups that don't end badly. Maybe co-workers will hear about it through the grapevine, if they don't maybe you should tell them yourself and help prevent somebody from making the same error you did. Sounds like maybe it's an easy mistake to make. . . and that means maybe the pumps need to be looked at? I work in adult so I don't deal with the same equipment you mentioned. But that's why errors should be reported. I'm sure you're not the first one to make such a mistake.

You'll be okay.

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at least no one dies. that shows that your only human able to commit mistakes sometimes,next time, always be cautious and never trust anyi-one unless you double check anything that you have to give to patients. take care and God bless!

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Specializes in CTICU.

Very few people have never set an IV pump incorrectly by accident. Usually you notice right away, sometimes it's a few minutes later. "Smart" pumps are there to help reduce these errors, just because they are so common. Do not think that you are in the wrong field because of one error. You'll make more.. just make sure you learn from them.

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Specializes in Medical-Surgical.

Learn from this mistake, but, my goodness, forgive yourself. You are human.

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As everyone already mentioned, we are human, and *all* of us have made mistakes! When you make one, you learn, and resolve never to make that mistake again.

I have seen many mistakes in my long career, made a few myself.

I knew a nurse who accidently pushed potassium into the IV line of a preemie-the baby lost an arm. She was horrified and almost quit. She didn't however, and is working as a nurse practitioner in NICU-she never forgot that dreadful error though.

Forgive yourself and move on.

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im so sorry! (hugs)

wait you were caring for 3 NICU babies by yourself? Im a nursing student but I thought that it was 1:1 or maybe 1:2 at the most...at least in adult ICU thats what it is. If im right, then thats totally unsafe work environment and id leave there asap

hopefully it all works out for you

The adult ICU also frequently run 3 to 1. Safe staffing laws exist in only one state, all other are directed by guidlines and allow the hospital to determine what is safe.

As to the error that this thread discusses, it may not have occured if staffing was safe. Let your self off the hook you are only part to blame. The condition the hospital put you in set you up for an eventual error as many studies have proven. Higher ratios increase risk of error and lead to increased lenght of stays and even patients deaths.

Support the CNA/NNOC and the campaign to bring California safe staffing laws nationwide. Contact the CNA at http://www.calnurses.org/

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Specializes in Medical.

I know how nauseatingly sick I feel when I make a significant error with an adult, even when no harm is done, so I really feel for you. As the other members have said, try to concentrate on the positive outcome rather than what could have happened, and use it as a learning experience.

You did everything you could once the error was discovered; where I work the focus of incident reports is on system causes rather than allocating blame, particularly if there isn't a pattern of mistakes. You clearly know the significance of the error, and I'm sure you won't ever make it again.

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I am so sorry this happened to you and the baby. We have all made mistakes. You seem like a very caring NICU nurse and you are just where you should be. I think it takes a real special person to work pedi, NICU and the E.R. Not everyone can do it. Thank God there are people like you that can. I am sure if you asked around the unit, everyone has made a mistake. It is a learning exp. and the baby is going to be ok. Maybe someone else will learn from your mistake too.

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Do not beat yourself up. Everyone makes mistakes and you learned from it. That is what matters. Don't quit. Talk to your coworkers. IF you need to see how many mistakes are made, ask about joining the peer review board. It will open your eyes and maybe heal your heart about yours. We are all human. Mistakes will be made but as long as you learn from them, that is what matters. THank god the baby was ok. Forgive yourself then cont being the great nurse you seem to be

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Life is too short to waste the integrity of your mental health over this mistake. Yes you will feel awful for a while that's ok. However the outcome was positive and hopefully you learned a valueable lesson. We are all human and your colleagues should be supporative because eventually all Nurses will make mistakes, some without the positive outcome you had.

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