major error in NICU

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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.

Oh, I am so sorry this happened, you practically had me in tears reading your post.:heartbeat I am thinking of you, hang in there... one step at a time, one day at a time, one week at a time...:kiss

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Thanks so much for all the words of support. :redpinkhe It helps to know that I am not the only one who has ever made a mistake. Our ratios are supposed to be 1:2 for intensive but it does not work out like that when we have 50 -60 babies. We are only staffed for about 48 babies. Luckily, I have 6 nights off to recover before I have to go back to work. I have been doing a lot of thinking about work. I am tired of the stress and nights and weekends..ect. I applied for a job doing case management and outreach for a non profit. I would go into homes and work with moms of preterm babies and children with health problems. Hopefully, it will all work out.

Regarding the IV pumps, I actually thought a few times that they are unsafe. I have worked with much better pumps with guardrails and separate buttons for rate and volume (the one I was using you have to scroll down. We only use the plum pump for the TPN. We use syringe pumps for everything else and they are also much safer. For small babies the syringe pump would be fine for TPN (we actually do that for for umbilical lines). I plan to mention all this to the risk assessment people. Not to defend myself, but hopefully to prevent it from happening to someone else.

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The way I see it, quitting should not even be in the back of your mind. This event will make you a BETTER nurse, so quitting would do a whole lot of people a big injustice! I'm not a nurse yet, but I know that mistakes do happen and you'll need some time to heal. I can only assume you'll feel better with time.

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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

depends on the area. One of my instructors is a NICU nurse & they have about 4 babies per nurse sometimes in the NICU she works in when she's not teaching us.

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hey, hey, hey. Nurses never quit. fight, fight,fight.life is a learning experience. you have to take it as a challenge.:loveya::loveya:

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Specializes in NICU, Post-partum.

The thing with nursing...is that even though both nurses and doctors make mistakes that can cause catastrophic injuries or even death...they are not robots, they are human.

I am a student, and I cannot imagine having something like this in my heart...I won't fully understand it, until I experience it...so I won't try to act like I understand what you are going through.

But please, you seem to be a very caring nurse, and the other posters are right...you had too many babies.

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all nurses. Code red pls. Can you pls:bowingpur:bowingpur:bowingpur suggest nursing service policies that is most important to all of you. I badly needed some to contribute in the formulation/revision of the nursing service association in our hospital...:idea::idea::bugeyes:

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Specializes in Infusion Nursing, Home Health Infusion.

OK so you made a mistake!!!!! What can you NOW do differently so it never happens again. This is what I do without fail EVERY time I start a drip or reset a pump. I needed to find something that was failproof since I see so many patients during my shift and often do not have the advantage of ever getting a report on them. So what I do every single time I do anything with an IV...including a start and site check,,,is to start at the top of the pump amd work my way to the site......check the rate....this is crucial...make sure the Volume to be infused is set correctly....has it been placed in the pump correctly...once on the pump is the clamp open......follow the tubing...make sure there are no clamps on or stopcocks are not turned in the wrong direction...next check where the IV tubing is connected..is it secure....is the CVC or PIV site OK.... it sounds like a long process but I do it so fast. I always check the bag as well and make sure it is correct and makes sense and it is for the right patient. This has worked for me my entire career and I am not going to change it now. I have caught many mistakes by nurses this way and they are always grateful that I checked. Also never increase a rate to prime your tubing...only use a prime feature or if not available to you with what you use just prime by gravity and attach your set. this is another way I have seen many mistakes and nurses get busy. I had a fellow nurse prime a lidocaine drip by increasing the rate from 20 to 220 and forgot to re-set it. The patient almost died as it was not caught right away. The nurse was upset with me b/c I had asked her to do the call b/c I was backlogged...I told her...... her policy should be as I stated and it never would have happened. Think about what I said b/c it works.

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Specializes in NICU, PICU, educator.

If anyone tells you they have never made an error, they are most likely lying!

You will learn from this mistake, and so will everyone else. Everyone always thinks that they would never do that or have it happen to them, but in reality, it will.

Because of several incidents like the one you had, we now have it in our P/P that two RN's must check the pumps once they are set and before the infusion starts. We have not had an error since then :) Maybe this can be suggested in your practice council. It is actually true for all units now where I work. Also, at change of shift we do line reconcilliations, which I believe all hospitals should be doing, where you trace the line from pump to patient, check rates, make sure tubings are still good. This is done between the on coming and the off going nurse.

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I can see it's been a while since you posted. I have recently been rethinking becoming an RN because of all of the potential mistakes that can happen. We always work short. My gosh-I freak out whenever I think I've done anything wrong, or if I think someone else thinks I've done something wrong. I once gave the incorrect amount of insulin to a patient. I think the only reason I kept my job is that I checked it with another nurse. We both interpeted a u for a zero. :scrying: That's when all med records were hand written. I followed policy. The patient was transfered to ICU and was on a sugar drip, but was okay. I know how you felt when that happened.

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Making mistakes is a terrible feeling. Unfortunately, the only person who will never make a mistake has hung up his or her stethoscope. Please be kind to yourself- no one- no doctor, no nurse- escapes healthcare without a mistake that haunts them. You have to forgive yourself, and know that this, too, will pass.

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Specializes in NICU.
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/

It's OK if you have the staff (I'm in California) but as a level II nursery we can have as many as four patients. That is common in our step-down, but three is not unusual in our NICU. Of course really sick babies are 1:1, but that often increases the ratio with the other babies. The big mistake was made when the safe staffing was enacted, no-one seemed to care as long as Level III nurseries got the 2:1 ratio.

Remember that when other states work on safe staffing!

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