Mistakes Are Inevitable: No One Is Perfect.

Ruby Vee, BSN

A former colleague of mine, a lovely woman I'll call Lauren, made an enormous and fatal medication error on her first night shift off of orientation. She gave 5 mg. of digoxin IV push-not 0.5 mg. She drew up and injected 10 vials of digoxin. She recognized her mistake almost immediately afterward, but it was too late for her patient. After a prolonged code, he died. Lauren learned a hard lesson, and she learned it in public, but she handled it in the best way I've ever seen anyone handle such a disaster. It's been 20 years, and Lauren went on to become a great nurse, a wonderful preceptor and now a nurse practitioner. How did she survive such a career-ending and license-shredding catastrophe? I'm going to tell you.

Everyone makes mistakes, absolutely everyone. There is no such thing as a perfect person, and since all nursing students, CNAs, LPNSs, RNs, and providers are human, there are no perfect nursing students, CNAs, nurses or providers. Nursing school doesn't really teach you to be a nurse; it just gives you a glimpse into the world of nursing. The NCLEX merely gives you a license to learn. If you're smart, you will learn something new every day of your career, and if you're very very smart, you'll learn how to handle those moments when you've been very, very stupid.

Anyone who tells you they have never made a mistake is either lying or too ignorant or stupid to realize they've made one. Understand from the very first moment that you don a set of scrubs and a name badge that says "Student", "CNA" or "Nurse", you WILL make a mistake. Mistakes are inevitable; they're part of life and they're part of nursing. What matters isn't that you're perfect; what matters is what you do after you've made that mistake.

I've known a few people who were so convinced of their own perfection that they couldn't recognize their own imperfections. If they did it or thought it, it must be correct. If you are not open to the possibility (inevitability) that you might make a mistake, you are not likely to realize when you've made one. If that thought doesn't scare the pants off of you, it should. If you are unable to recognize having made a mistake, it will be impossible for you (or anyone else) to fix it. The very first thing to do when you've made a mistake is to recognize it. The second thing to do is admit it.

Admitting a mistake is scary and difficult. No one wants to appear stupid, no one welcomes the idea that others might be judging them. But our job is too important not to admit our mistakes, and the stakes-for other people-are far too high.

It's amazing how resilient patients can be, and how few medical mistakes actually kill patients or even cause them permanent injury. Some do-we all know that. Anyone who has heard of Peter Pronovost knows that safety is a huge concern in hospitals today. But if you recognize your mistake, admit it, and immediately set about to minimize or mitigate the damage, most mistakes are merely a bump in the road rather than a career ending or life changing catastrophe.

Years ago, I worked in a SICU with a nurse I'll call Janet. Janet was beautiful, funny, smart and generous. I met her my first week on the job, and we became friends immediately. We went hiking and biking and dining and dancing, and we always had a great time together. Janet was a lot of fun. But she also lacked integrity. One day I was in her room with her at work, helping her to turn her fresh-from-the-OR patient. As we turned him, we heard the monitor start to alarm, and we looked up in horror to see his heart rate slowing down, passing 30 on the way south. The surgery fellow was just outside the room and responded instantly to my involuntary utterance of an expletive that means fecal material.

There were many interventions, but the one that sticks forever in my mind was the order to give "Point one milligram of epinephrine." Janet grabbed up the emergency bristojet of epi at the bedside and pushed the entire thing-one milligram. Suddenly we had the opposite problem. The patient's heart rate picked up-slowly at first-but rapidly gathering steam. From no blood pressure and a flat art line, we suddenly had a pressure of 250 systolic and climbing, and a heart rate in the 200s. "How much epi did you give?" shouted the fellow in alarm.

"What you said," was Janet's reply as she slid the empty syringe out of view.

"How much was that?"

"What you said!"

"How much was ordered?"

"I gave what you said," she insisted, despite the clear evidence to the contrary. The chest tubes were full of blood and the pleurevac overflowing. We whisked the patient back to the OR, leaving a bright red trail of blood in his wake. Janet never budged from her story-never. Her mistake didn't kill her patient because the quick thinking and quicker actions of that surgery fellow, but I never trusted her again, and it was pretty much the death of our friendship. The fellow-who is now head of surgery at the hospital where Janet still works-has never trusted her again either. He's put an end to more than one promotional opportunity she's set her sights on.

As soon as you recognize that you've made a mistake, tell the appropriate person. It's not enough that you recognize and admit your mistake; the next thing is to do everything you possibly can to prevent, minimize or mitigate the damage. If you've made a medication error, tell the provider. There may be, and usually is something that can be done. Narcan reverses a narcotic overdose, protamine reverses a heparin overdose and if you've given too much insulin, you can give sugar. But you'll need a provider's input and a provider's order.

Once you've done what you can to help the patient, take a moment to think through the process that led to your error. Were you rushed? Distracted? Overtired from overtime? Didn't understand the order? Whatever the cause, you need an understanding of how and why you made your error and what you're going to do differently next time to prevent it from happening again.

You're going to have to tell your manager. There are right ways and wrong ways to tell your manager, but whatever you do, make sure YOU tell her before she finds out from someone else. This is even more important if it was a big mistake or if the consequences to the patient were dire. Call her at home, email her-whatever it takes. There's nothing worse from a manager's perspective than to be blindsided by someone who comes to confront her about a mistake made by a member of her staff. Even if you don't have time to write down the particulars, make sure your manager knows you made the mistake before someone else tells her.

A colleague of mine once shocked a patient in normal sinus rhythm because he mistook artifact for V tach. He was new to ICU, and some artifact does look a lot like V tach or V fib. Dan "defibrillated" his patient in full view of an entire team of doctors and a couple of nurses, most of whom were yelling at him to stop.

"Oops," he said afterward, with a laugh. "I shouldn't have done that." No one else was amused. Our boss wasn't terribly amused either, when she heard the story and Dan is long gone from our unit.

You want to make it perfectly clear to your boss that you realize you've made a mistake, that you understand that the consequences were (or could have been) humungous, and that you're profoundly upset with yourself, sorry for your error and worried about the patient. You also want her to know that you've thought through the process that led to your error and that you have a plan for making sure it never happens again. I can tell you from personal experience that you can survive a sentinel error with your job and your license intact-if you recognize your error, admit it, tell the people who need to know, set about to mitigate the damage and tell your manager in the right way. Lauren not only survived but went on to thrive in her nursing career-not because she never made a mistake, but because she showed enormous integrity in what she did after she made one.

Last, but far from least, forgive yourself and move on. That's often the most difficult part of the entire process. But NOT moving on condemns you to relive your mistake over and over again, undermining your confidence, destroying your sleep and making it far more likely you'll make more mistakes. That's a vicious cycle. Forgiving yourself isn't easy-I'm still working on it-but it is necessary. Writing helps me to move on, others may benefit from talking to a therapist or counselor. If that's what it takes, do it. Some workplaces even offer counseling as a benefit to employees who have been a part of a sentinel event.

You WILL make a mistake-just make sure you deal with it with honesty and integrity.

Mistakes Are Inevitable: No One Is Perfect.

About Ruby Vee, BSN

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