Mistake

Nurses General Nursing

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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.

Specializes in ICU, ER, Home Health, Corrections, School Nurse.

I truly feel sorry for the pain that you have felt through the years. You say that you have been in counseling. The amount of pain you are feeling is pretty disproportionate to the event that occurred, considering it's been 12 years. I really think there is something else going on in your life, that has not been addressed, (or at least not adequately addressed). I would perhaps suggest a new counselor, or taking counseling in a different direction. I am not by any means trying to diagnose you, but it almost seems like you are exhibiting some symptoms of PTSD, as you were very traumatized by the event. There are several new approaches to treating PTSD, that are remarkably effective. Again, I am not trying to diagnose, or label, and maybe you are already addressing this. I hope you find the peace that will let you move forward.

I am so blessed to have all of your comments, I feel so alone. I have not seen a counselor yet, since I am new, I have to wait for an opening in March. I picked a counselor that is an APN, I wanted someone that understood nursing. I did begin an antidepressant and I have even talked with a priest. Nursy, I think you are right. I was fine for a number of years, it would surface here and there but not like this. I saw a story on the news about a police officer not going into a building to help people during a shooting and everyone was condemning him, and I thought of myself, a coward and putting myself first. As a nurse, I need to put the patient first and I failed. I cannot forgive myself. And I feel like I won't feel better until I know for sure that the person is OK. Everything feels so different, the depression is terrible. It does feel like a PTSD.

Wishing you peace with yourself, Marie63. I'm happy you are taking the steps to move forward from this. As a nurse with a history of terrible, terrible depression which worsened after being involved in a sentinel event, I know your pain. Take care. ❤️

Safetypin, BSN,RN, thank you and bless you.

Specializes in NICU/Neonatal transport.
On 2/25/2019 at 6:15 PM, LibraNurse27 said:

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!

That is not necessarily true. most oral meds are not sterile, and the osmolarity is different, so giving a PO med IV usually will have consequences.

That's not to say at 12 years you should still be down on yourself.

I won't lie and say I don't have two minds of mistakes, because it depends on the level of error and how many steps and how negligent it was. I think it is possible to come back from error, even potentially one of gross negligence, and still be able to practice and be a good nurse, but I'm not sure it is necessarily so or in the best interest of anyone.

Errors that have small errors that many people had a hand in, those are way harder to accept or place responsibility on any one person. we all make those small mistakes. I think each error needs to be evaluated as to what personal responsibility each person should face. Sometimes its your own conscience alone that can determine that, but a therapist will likely help.

I agree coming forward about your mistakes immediately is key, both for the patient, and your own conscience.

I'm glad you are going to see someone. You need to find a way to move forward, no matter what.

Specializes in NICU.

You are crazy,get help,real help,then move to another country before you make yourself sick with self flagellation, anyone one can make a mistake we are only humans doing the best we can under difficult situations,best wishes for your healing.

Specializes in ICU / PCU / Telemetry / Oncology.

While I agree that nurses should be encouraged to report their mistakes without fear of retribution or blame, we must be assured that we are in a culture that this is a guarantee. As long as we see even an isolated detour of this guarantee, we will continue to be shutmouthed. As such is the case somewhat of the Vanderbilt nurse currently in the news of whose name escapes me right now.

By the same token, nurses should not be admonished for legitimately calling out sick for having the flu or what not. We are encouraged to call out sick when we are contagious but get written up for staying out sick too much?

The hypocrisy needs to stop. No wonder nurses feel undervalued and are leaving the bedside by the truckload ... ?

Specializes in NICU/Neonatal transport.
2 hours ago, PacoUSA said:

While I agree that nurses should be encouraged to report their mistakes without fear of retribution or blame, we must be assured that we are in a culture that this is a guarantee. As long as we see even an isolated detour of this guarantee, we will continue to be shutmouthed. As such is the case somewhat of the Vanderbilt nurse currently in the news of whose name escapes me right now.

By the same token, nurses should not be admonished for legitimately calling out sick for having the flu or what not. We are encouraged to call out sick when we are contagious but get written up for staying out sick too much?

The hypocrisy needs to stop. No wonder nurses feel undervalued and are leaving the bedside by the truckload ... ?

The vanderbilt thing though is the same thing that gives me pause though, not in the same way as you. It gives me pause in absolving all errors. Because I don't consider what she did an error. It was a total abandonment and dereliction of nursing duty. I'm not as quick to say "oh yeah, that's something everyone will do, don't beat yourself up", because of her situation. Because no one should be in her situation - while there could have been things that would have saved the patient's life, nothing changes the fact that the "nurse" didn't even try to be a nurse.

Specializes in Pediatrics.

I agree very much with the above posters. I have also had a serious med error and right after I realized it I had the urge to hide it, but I figured what happens if everyone knows right away will be better than being caught lying, no matter what. Through a lucky series of events the patient had no physical consequences, and I learned that my error was the last in a chain of them. But of course being the one who caught and reported mine, I was the one who took the fall. A few changes were made in the protocol as a result of my error and I did not lose my job, but my confidence was shattered and I am still recovering. Go easy on yourself. Let yourself be human and you still have much to offer patients.

On 2/25/2019 at 12:25 PM, Marie63 said:

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.

Report and get charged with negligent homicide, I would not. That being said let yourself off the hook, we have all made mistakes. When I was new things were not so punitive.

14 hours ago, LilPeanut said:

The vanderbilt thing though is the same thing that gives me pause though, not in the same way as you. It gives me pause in absolving all errors. Because I don't consider what she did an error. It was a total abandonment and dereliction of nursing duty. I'm not as quick to say "oh yeah, that's something everyone will do, don't beat yourself up", because of her situation. Because no one should be in her situation - while there could have been things that would have saved the patient's life, nothing changes the fact that the "nurse" didn't even try to be a nurse.

I have to agree with you, this "error" was in a category of its own. I can see a nurse losing her/his license for something of this gravity. However, I disagree with the negligent homicide charges.

Sadly, however, many nurses (like my friend who lost her job for a relatively minor error which caused no harm) face serious consequences for their honesty. As long as this persists, many errors will continue to be covered up, possibly resulting in harm to patients ... and ultimately the responsible nurses, as the op's story illustrates.

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