Mistake

[Marie63]

I am new to this site.

I joined because I am suffering from such depression and anxiety over a mistake I made as an RN 12 years ago, hoping to get some help and give help - so other nurses do not suffer from what I am going through.

While working on an Admission Unit at a local hospital 12 years ago, I had a patient, an older, alert, oriented woman that came through the ER and then to the Admission Unit ( we performed the initial assessment, obtained admission orders, began IV, gave initial meds etc).

She was being admitted, but I cannot recall why or the patient's name.

I did not do the initial assessment.

When her meds came up from pharmacy, I had to give them to her, and then she was transferred about 10 minutes later to her inpatient room. I gave her oral meds and a luer lock clear syringe also came up from pharmacy and I assumed that it was to be given through her IV. So I gave it through her IV line. After I gave it ( I cannot even remember the name of the med), the patient stated that she usually took that medicine by mouth at home.

Her husband was also present. I just said, "Oh you do?" I then looked at the MAR and it said that the medicine was to be given PO.

The patient was transferred to her inpatient room a few minutes after I gave the medicine and from when I noticed my error. I did NOT report my error to the patient or to the staff or to my supervisor.

I did NOT complete an incident report. I kept my mistake to myself.

I ended up quitting the job approximately 1 month later due to the stress of the job.

At that time, I reported my error to my Supervisor. But I did not recall any information ie: patient's name, date of incident, name of med etc. She said that there were no incidents that she could recall that were ever reported to her.

I have thought about this and my failure as a nurse through out the years, worrying about the patient. Two months ago, I even wrote a letter to the Chief Medical Officer of the hospital, identifying myself and explaining the incident.

I feel like such a terrible nurse. I don't know why I didn't report it at the time, busy? afraid of looking stupid? being yelled at?

In any case, there is NO excuse, I put myself first and to this day I worry that I may have been responsible for a patient's death.

The Chief Medical Director did write me back and said that there was an incident where the pharmacy sent an IV dose instead of the oral to the floor, even though the MAR stated PO. But we don't know if this was "my" patient for sure.

The Medical Director asked if he could use my story, without using my name, to encourage nurses and doctors to speak up about their mistakes. There are burdens when we don't report.

I am hoping nurses out there, ALWAYS report your mistakes.

Do not feel like you are alone making them and don't worry about looking stupid. It is not worth the suffering that I am going through.

I have even taken a medical leave from my current job and plan to start counseling. I have not been able to eat and it is affecting my family. I have even talked with a priest and I still don't forgive myself.

PLEASE report ALL mistakes.

And hopefully, there are in-services and supportive supervisors for staff, to encourage reporting and to know that they are not alone in making mistakes.

[Ruby Vee, BSN]

I hope that if you had taken ownership of your mistake all those years ago, you would be able to forgive yourself now. But that's water under the bridge. I'm glad you're getting counseling, and I hope you are able to forgive yourself moving forward. You are doing the right things now.

So that other nurses reading this may learn from it -- we all make mistakes. Every single one of us. We are all human, and humans make mistakes. What matters the most is what you do AFTER you've made the mistake. Admit to it as soon as you've realized you made a mistake, and set about mitigating the damage to the patient. Report your mistake, and be able to describe what you learned from making the mistake as well as how you'll keep from making the same mistake in the future. And then the hardest part -- forgiving yourself.

It's been more than 12 years since I was part of a sentinel event that changed a patient's life forever. The difference between my mistake and yours was that there was no hope of covering it up -- not that I would have done so anyway. The whole hospital learned of my mistake, and even though it was part of a perfect storm of communication failures, and I was only the last link in a chain, any link of which could have changed matters and prevented the mistake, the buck stopped with me. Everyone, it seemed, blamed me and I was notorious for YEARS for having made that mistake. No one else who could have prevented it accepted their own responsibility, and I was raked over the coals publicly and privately. I stood up, did the right thing, and took my lumps. It wasn't easy, but it was the right thing to do. I kept my job, and my license. Eventually, I earned back the respect of my peers and the rest of the health care team. That wasn't easy, either.

It is only because I know I did the right thing that I was able to eventually forgive myself. Mostly. I still wake up in a cold sweat now and again, transported right there to that time and place. That's getting less frequent now.

I really hope you get the healing you need.

[Sour Lemon]

This seems like a severe overreaction unless there was some significant harm done to the patient. It makes me wonder what else might be going on in your life.
I'm not sure if this will help or make things worse, but you've probably done other things just as bad without ever being aware that you did them.

I'm wishing for peace for you.

[ruby_jane, BSN, RN]

On 2/25/2019 at 3:38 PM, Ruby Vee said:

It is only because I know I did the right thing that I was able to eventually forgive myself. Mostly. I still wake up in a cold sweat now and again, transported right there to that time and place. That's getting less frequent now.

Hats off to you, Ruby, for your unflinching honesty about yourself, the incident, and what happened afterward. Sometimes we learn to do the right thing by doing the wrong thing.

[VivaLasViejas, ASN, RN]

I'm sorry you're still feeling guilty so many years after the incident, but glad you're getting some counseling. Twelve years is far too long to punish yourself for a mistake. I hope you will find a way to forgive yourself and find peace. My thoughts and prayers are with you.

[TriciaJ, RN]

If nothing was ever reported back to the hospital, there's a good chance your error did nothing at all. What would that patient think to find out you've been torturing yourself all these years over a non-issue?

That is another good reason to report your errors right away. If you luckily did not harm anyone, you find out right away and don't have to spend years wondering.

Wishing you and Ruby both peace and continued healing.

[Marie63]

Thank you for your comments. I hear a story about someone being negligent or not honest, and it triggers my guilt and shame. I feel so alone, it is comforting to hear from other nurses that truly care about their patients. My daughter recently graduated with her BSN and I have shared my story. I am hoping others learn from my mistake.

[DeLana_RN, BSN, RN]

4 hours ago, Ruby Vee said:

So that other nurses reading this may learn from it -- we all make mistakes. Every single one of us. We are all human, and humans make mistakes. What matters the most is what you do AFTER you've made the mistake. Admit to it as soon as you've realized you made a mistake, and set about mitigating the damage to the patient. Report your mistake, and be able to describe what you learned from making the mistake as well as how you'll keep from making the same mistake in the future. And then the hardest part -- forgiving yourself.

That's nice, and how it should be. But you may also end up like my best friend, who was terminated for her only med error in 5 years, self-reported, no harm came to the patient... the real reason was of course that the manager wanted to get rid of her and took advantage of this opportunity. Just saying, this can happen in an at-will employment state with no union protection.

My friend knew that she could have easily covered the mistake up, but even knowing the outcome (which she would have never expected), she would do exactly the same thing again. Because a clear conscience is more important than even the worst (unfair) punishment.

OP, please do what my friend ultimately did - get counseling. If you do, you will be fine.

Wishing you all the best.

[Davey Do]

Wow. Just: wow wow wow wow.

I am moved by your post and my heart goes out to you Marie. I actually feel your pain and want to send you good healing vibes.

I have my own story which is similar to yours and I wrestle with it still. Do we ever truly forgive ourselves, even after therapeutically facing and dealing with it?

Maybe knowing that I could have once made a catastrophic error that led to a patient's demise keeps me humble and keeps me from getting too damned arrogant.

The very, very beat to you, Marie.

[LibraNurse27, BSN, RN]

I’m pretty sure if something bad happened to the patient you would have heard about it but I guess if you don’t remember the patient’s name there is no way to know for sure, which I’m sure is the frustrating part. Do you remember which med? Most of the oral meds I can think of that would come liquid in a syringe wouldn’t seem to do harm given IV other than irritating the vein and maybe blowing the IV. I have seen one nurse give a syringe full of a PO multivitamin solution through an IV and it burned the patient’s vein and caused phlebitis but other than that no issues. Not to say it’s not important to check the route! Just trying to make you hopeful that you didn’t cause harm and I’m sure you have learned from your mistake and improved your practice. Time to move on!

[TriciaJ, RN]

Oral liquid medications that come in syringes have big labels that say "ORAL MED". The syringes are also shaped a bit differently. I have a feeling this is not because only one person in the whole world mistook it for a parenteral med.

I'm pretty sure the change came about because this is a commoner error than you think.

[dream'n, BSN, RN]

Yes you made the wrong choice those many years ago, but the fact that your conscience has been eating at you for all these years shows what a caring, empathetic person you are. Please remember what is done is done. You learned a very painful lesson, now it is time to let it go. Holding on to this pain changes nothing, it will only continue to destroy you more. A person is not defined by one moment of their life, and this does not negate many of the wonderful qualities I'm sure you have. Please get counseling, please forgive yourself. Right now the pain you are experiencing has no purpose in continuing, there are no more lessons for it teach you.

New nurses listen to Marie's advice and remember that a mistake that is reported can often be rectified and worse come to worse can be somewhat explained to the BON; everyone is human and you will also be able to look at yourself in a mirror. You will know that yes you screwed up but you did your very best to rectify it.

Thank you for sharing your story Marie I know it couldn't have been easy. I hope peace comes to your heart.