making mistakes

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Just wanted to get some feedback for all you M/S nurses out there. How do you deal with being called out on mistakes? We all make them right?

I made a pretty serious error at work that I wasn't even aware of until management pulled me aside and asked me about. I had a patient with a peg tube, who was to start a tube feed. The order read: Start tube feed at 20 cc/hr, increase by 10cc/hr until goal rate 60 cc/hr is reached, Q8 hours. Well I misread the "Q8" part, I started at the 20 cc/hr and went up every hour until he was the goal rate of 60 cc/hr at the end of my shift. The rate should only have increased by 10cc/hr every 8 hours. During this time there was no residual and The patient was tolerating it, and didn't have any complaints of nausea or abd pain. I reported off, and the night nurse left it at 60/hr for her 12 hour shift. The next morning the patient started vomiting, he developed an ileus.

Anyway, I didn't get written up, Manager said she had to read the order several times herself. But I can't stop thinking about it. I got such a bad feeling in the pit of my stomach. I hate to think I could have caused harm to patient. I usually read all of my orders very carefully but I was very tired that day and I dropped the ball. Now I wonder about other possible mistakes I could have made in the past and not even know about. I've been a M/S nurse for 5 years now by the way

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Specializes in CMSRN.

Mistakes suck but yes, we all make them.

I hate how that order was written. It seems like it could have been written more clearly with something like "start tube feeding 20 ml/hr. Increase by 10 ml/hr q8hours until max of 60 ml/hr reached". I really feel I could have easily made a mistake with that as well.

I've had an issue with heparin nomograms before and absolutely hate feeling inadequate at reading them.

Keep your head up and know you're human but are trying to learn from this to prevent it from happening again. That's all any of us can do.

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Specializes in ER LTC MED SURG CLINICS UROLOGY.

Oh that's fine. Lol. It was a learning experience. We have tons of those in nursing!!!😂😂😂

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Thanks for your responses. It definitely was a learning experience.

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I thought the same thing when I read your order. It is confusing.

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Specializes in Post Acute, Home, Inpatient, Hospice/Pall Care.
Just wanted to get some feedback for all you M/S nurses out there. How do you deal with being called out on mistakes? We all make them right?

I made a pretty serious error at work that I wasn't even aware of until management pulled me aside and asked me about. I had a patient with a peg tube, who was to start a tube feed. The order read: Start tube feed at 20 cc/hr, increase by 10cc/hr until goal rate 60 cc/hr is reached, Q8 hours. Well I misread the "Q8" part, I started at the 20 cc/hr and went up every hour until he was the goal rate of 60 cc/hr at the end of my shift. The rate should only have increased by 10cc/hr every 8 hours. During this time there was no residual and The patient was tolerating it, and didn't have any complaints of nausea or abd pain. I reported off, and the night nurse left it at 60/hr for her 12 hour shift. The next morning the patient started vomiting, he developed an ileus.

Anyway, I didn't get written up, Manager said she had to read the order several times herself. But I can't stop thinking about it. I got such a bad feeling in the pit of my stomach. I hate to think I could have caused harm to patient. I usually read all of my orders very carefully but I was very tired that day and I dropped the ball. Now I wonder about other possible mistakes I could have made in the past and not even know about. I've been a M/S nurse for 5 years now by the way

Oh man I don't like the way that order is written, I could see many people making that mistake. At least they used it as a learning experience and not a punishment, sounds like good people!

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