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Making a Mistake on Something You Normally Excel At

Posted

Specializes in Rehab/Nurse Manager. Has 6 years experience.

Have you ever made a mistake on something you normally do well with? 

For me, this happened this past week, but I didn't find out about it until today.  Basically, what happened was that someone didn't receive a medication for a week because the order was never entered during admission.  I was the one thar originally entered the orders.   There were at least 2 other people after me who double checked and didn't catch it either, although that is beside the point.  Other than blood pressures elevated slightly from baseline, the patient is fine.  Obviously, though, there was risk for harm if her BP wemt too high.  Also, I take pride in not making errors like these, so for me, I'm gravely disappointed in myself.  I'm appalled that this happened because normally I'm very good at entering orders (no errors in the last 2+ years until today) and have no good explanation for why it happened, other than I was constantly being interrupted by others while trying to put these orders in. 

Who else has experienced something similar? How did you recover? 

I will say I will no longer be as enthusiastic to enter orders.  I'll still do them, obviously, but I won't be seeking them out or competing to do them anymore. 

 

 

SilverBells, BSN

Specializes in Rehab/Nurse Manager. Has 6 years experience.

I will also no longer be actively seeking the more complex admissions or the ones with many orders.  If I happen to get assigned one, that's fine, but I won't be pursuing them either

SilverBells, BSN

Specializes in Rehab/Nurse Manager. Has 6 years experience.

Could simply be just a mistake, but I'm wondering if this is a little karma coming back at me for choosing to do this admission rather than helping a hospice patient (who I'm now hearing was in distress) and doing that admission instead last week. 

JBMmom, MSN, NP

Specializes in Long term care; med-surg; critical care. Has 9 years experience.

We all make mistakes. This is certainly nothing to make you question your abilities as a whole. As you mentioned, there were numerous things going on that night and it was one order that was overlooked. Fortunately no harm came to your patient. How do you recover? You move on, with the knowledge that you're human, you did nothing with bad intent and the patient is fine. Take care. 

SilverBells, BSN

Specializes in Rehab/Nurse Manager. Has 6 years experience.

Strangely enough, I was scolded more for not jumping up to assist getting the hospice patient from his wheelchair into bed than I was for this transcription error.  To me, a patient missing an important medication for days is more significant than someone having to wait a few minutes to get into bed, but go figure. 

JBMmom, MSN, NP

Specializes in Long term care; med-surg; critical care. Has 9 years experience.

14 minutes ago, SilverBells said:

Strangely enough, I was scolded more for not jumping up to assist getting the hospice patient from his wheelchair into bed than I was for this transcription error.  To me, a patient missing an important medication for days is more significant than someone having to wait a few minutes to get into bed, but go figure. 

Maybe medically an error like this seems worse, but the human side of people will pick up on importance of providing care to the hospice patient. I was one of the people that couldn't for the life of me figure out how you thought the best thing was to "decline" to help reposition that patient. Errors like the transcription error happen every day, you're human, you were busy and there could have been numerous distractions, that's just an error. Making the active decision to not assist a patient, especially at the request of the patient and family, indicates a judgment error and that's more concerning. 

hppygr8ful, ASN, RN, EMT-I

Specializes in Psych, Addictions, SOL (Student of Life). Has 19 years experience.

On 9/21/2021 at 5:14 PM, SilverBells said:

 

Who else has experienced something similar? How did you recover? 

Yes I have made this type of error in the past. This actually qualifies as a medication variance. Since the patient suffered no harm, you should use this as a learning experience.

When it happened to me I was told to recognize I was human and that humans make mistakes. I took ownership and moved on. 

Hppy

SilverBells, BSN

Specializes in Rehab/Nurse Manager. Has 6 years experience.

19 hours ago, JBMmom said:

Maybe medically an error like this seems worse, but the human side of people will pick up on importance of providing care to the hospice patient. I was one of the people that couldn't for the life of me figure out how you thought the best thing was to "decline" to help reposition that patient. Errors like the transcription error happen every day, you're human, you were busy and there could have been numerous distractions, that's just an error. Making the active decision to not assist a patient, especially at the request of the patient and family, indicates a judgment error and that's more concerning. 

When you put it like that, it makes sense.  One situation was a genuine mistake (the transcription error) whereas the other was a deliberate action (waiting for the assigned nurse to help get an uncomfortable hospice patient into bed).  Also, the patient who didn't receive her blood pressure medication didn't really experience any ill effects,  but the hospice patient was probably more uncomfortable for longer than he should have been. What I had been doing at that moment could have waited until the hospice patient was more comfortable.  

Aren’t you a manager?  If you can’t do a basic admission, how are you a manager?  Sorry, SilverBells, I find your posts less and l as believable.  Or you work for an extremely incompetent company that put you in charge.
 

If you are indeed a nurse manager, why would you have to seek out complex admissions?  
 

My manager asked me if my pod needed help a few weeks ago, we were super busy so I said yes, come in and help with this admission.  Which she gratefully did.  But she didn’t do the actual admission and she left the pod shortly after.  I appreciated her jumping in but never would she be responsible for the patients or actual admission.   

SilverBells, BSN

Specializes in Rehab/Nurse Manager. Has 6 years experience.

7 minutes ago, LovingLife123 said:

Aren’t you a manager?  If you can’t do a basic admission, how are you a manager?  Sorry, SilverBells, I find your posts less and l as believable.  Or you work for an extremely incompetent company that put you in charge.
 

If you are indeed a nurse manager, why would you have to seek out complex admissions?  
 

My manager asked me if my pod needed help a few weeks ago, we were super busy so I said yes, come in and help with this admission.  Which she gratefully did.  But she didn’t do the actual admission and she left the pod shortly after.  I appreciated her jumping in but never would she be responsible for the patients or actual admission.   

I am capable of doing an "easier" admission, but generally seek out the more complex admissions to help save the floor nurses time.  More is involved with these patients' assessments and there are more orders to enter and double check, so I usually see it as a way to help the staff out.  

With that said, you had mentioned that your manager had recently helped with an admission but didn’t due the entire thing.  In what ways did she assist?  What did she do that you found helpful? 

SilverBells, BSN

Specializes in Rehab/Nurse Manager. Has 6 years experience.

With that said, there's probably no reason for me to continue seeking out the lengthier admissions. This thread clearly shows that I am also not immune to making these mistakes.  Before this, I had confidence in myself to complete these longer admissions without making any errors 

Edited by SilverBells