Mistake!

[krenee]

I've been working on a postpartum/newborn nursery unit for 7 months now. MOST of the time I'm feeling pretty good about how I'm doing, but of course I do make mistakes from time to time. Usually just stupid things like forgetting to sign something on the chart. Yesterday, however, was one of the bigger ones I've made. I called a doctor with lab results on a baby and received an order to stop phototherapy - or so I thought. I heard later that the doctor denied giving that order. I can only assume the dr. said CONTINUE photo and I heard DIS-continue. What I'm afraid of is that I must not have read back the order like we're supposed to. The baby had to go back under the lights and the mom was upset that she had to be discharged and leave the baby. The worst part is that when I got the lab results I wasn't expecting the phototherapy to be stopped, and I told the mom that too. So I don't know why I heard it wrong.

Anyway - it's just hard to go back to work today after making that mistake and even having to see that baby or the mom, or the doctor . . . and I don't know whether I've been written up for it or not. The nurse who told me about it (my former preceptor) was very nice about it, told me not to worry, etc. but I can't help but worry & be upset. And I know I won't feel better until that baby is discharged. I know making mistakes can be the best way to learn but I HATE it, sometimes I wish I were at a desk job where mistakes didn't matter so much.

Well, mostly venting & thanks for reading.

[Jolie, BSN]

This is a good topic of dicussion with your charge nurse or manager.

Hospitals once typically stonewalled families seeking information about possible mistake for fear of litigation. Numerous studies conducted by health care organizations, risk managers and legal professionals have shown that hospitals that come forth with the truthful information in a timely manner are much less likely to be sued than those that don't.

I'll give you a few examples. The first is my own story. I had undergone years of treatment for infertility and finally had a (+) pregnancy test. A few weeks later, I had suspicions that things weren't right. I consulted my infertility specialist, who was unavailable and referred me to a colleague. He never examined me, only ordered a few tests that did not reveal a problem. Not satisfied, I pushed up my first OB appointment and shared my concerns with her. She did a pelvic exam, and later revealed that she suspected a problem, but didn't act on it because she was falsely reassured by the test results from the other doctor. A few weeks later, I had a ruptured tubal pregnancy during a terrible winter storm and had no choice but to be treated at a near-by rural hospital by a doctor I'd never met. He saved my life and fixed up my tubes.

Once recovered, I met with both of the other doctors. They discussed their errors in judgement, over-reliance on technology versus asessment skills and convinced me that they would never make those mistakes again. I chose not to return to their care, but was satisfied that there was no malice, and an honest intent to improve their practices in the future.

Suing may have netted me something, but required time and energy I thought was better spent on pursuing a pregnancy. Their forthrightness saved us all a lot of anguish from a lawsuit.

I also had the very sad experience of working on a L&D unit when a fetus died during delivery due to an undiagnosed condition. (I'm going to be vague here.) The OB could not have reasonably known or suspected the condition in advance. When the mom arrived in labor, it was obvious there was a problem, and the OB immediately came in, but the baby was already gone. Nothing could have changed the outcome.

But the OB was very inept at communicating, even on a good day. He didn't speak to the parents about the loss. He left that to the nursing staff. The parents were upset about it, and understandably unable to move forward. The case ultimately resulted in a lawsuit that had no merit in terms of actual malpractice, only poor communication.

Most facilities now recognize the importance of honest communication about errors and the value of this in resolving potential litigation before it ever happens.

In a situation like yours, where no real harm came to the baby, most parents simply want to know that corrective action has been taken to avoid it from happening again to themselves or someone else.

[NotReady4PrimeTime, RN]

I have to agree with Jolie, again from personal experience. My son was permanently and significantly injured as the result of medical misadventure. (I use that term deliberately, because I genuinely believe there was no intent to harm, and the practice that led to his injury has changed.) If the doctor involved had even just once said he was sorry for what happened, we could have accepted that and moved on. But he never, not once, said he was sorry. Not for the three additional months of hospitalisation, not for the lost future, not for the profound changes his inattention brought all of us. I don't for a second think that any of us in health care is infallible... we are all human after all. Then why is it so hard for us to say, "I made a mistake. I'm very sorry. I won't do it again"?

[BedsideNurse]

I've been a nurse since 1995 and I've come to the realization that if nobody died or was permenantly harmed by a mistake than not to obsess about it. Everyone feels bad after they make a mistake--playing it over and over in your head, feeling guilty, upset, whatever. Try not to. There are worse scenarios and in the scheme of your nursing life. So although it's kind of a bummer, it's certainly not something you should let haunt you. Like I said, if no one was hurt or died, just try to figure out how to avoid doing it or something similiar in the future and MOVE ON. We do one million things a day, once in a while we are going to misstep. Be glad it's something fixable (some things aren't).