Mistakes held against you

[mugwump]

I was wondering if anyone did an error big or small would you feel comfortable reporting it. Or would you feel that it would be held against you.

[q12RN]

IMO, if you messed up you need to report it asap. If you try to hide it and act as if it never happened then that makes it much worse.

[SmilingBluEyes]

I made a huge error with pitocin on a VBAC patient once-----one that could have had disastrous consequences. I did report my error via the incident reporting system and to the involved OB (the one who happens to be the meanest one we have). Oh yes, it was horrible...I still have chills just thinking about it...the patient and baby turned out fine, but no thanks to ME.

So the anwer is yes, and yes, I felt sick about it for weeks after ward. I thought for sure all my coworkers would distrust me or give me "fish eye" but they did not. They were incredibly supportive and understanding, and respected me, it seemed. But I did report it, to risk mgt, the dr, my managers and also---and I was very open w/my coworkers about what I had done and how to prevent it later on.

[nursingisworkRN]

Just to add my opinion, it is best to take the high road and report it. The incident report is used to identify areas of weakness that need improvement for safety. Plus, I do think it helps to build integrity and honesty if you are forthcoming. Everybody makes mistakes, but it is always best not to hide them. And I guarantee after the incident report you will not make the same error/mistake/omission/whatever incident was again.

Plus, it really isn't that bad calling the doctor to report the error. They usually appreciate being informed. This happened to me once and I was made fun of by a coworker and prepared myself for a public flogging by the md. The md was surprisingly calm and nice to me. It was not a big deal in terms of consequences for me or the pt, but iv fluids weren't running and I gave meds that were ordered to be held. OOPS! I just about had a MI! And I did significantly drop the bp on the cardioversion pt and bought them an extra 4 hours in the CCU. Live and learn. I won't do that again. I was so hard on myself that I don't think the doctor could have made me feel worse anyways, but I do appreciate how professional he was.

[StNeotser, ASN, RN]

We've all made mistakes, big and small.

I've given coumadin to a patient with a critical high INR, unfortunately, the Drs order was given by fax to hold, I didn't even know the patient had a blood draw that day due to a bad report. The order was put on the nurses station minutes after I had given the coumadin.

I had to report it and take the blame.

It's far easier if you do report your error quickly. You do not want to have to report your error in front of a judge and jury.

Like I say, even the best nurses make mistakes sometimes.

[oneLoneNurse]

The higher echelons in our hospital know that the % of errors we have is not valid. Our nurses are under reporting their errors. I think most hospitals may be guility of that. We discussed for years how to get nurses to report their errors. There is no easy solution to this problem. As a result your inline supervisor might hold it against you if you report too many, because of the paper work, BUT don't think the DON and/or others will unless you do not correct the processes that may be causing you to make the error.

Since I switched back to floor nursing (last year) I have reported all my errors. Sorry, to say I have had 3 over the last year. Noone has glanced an evil eye on me.

1) gave haldol to a patient who has an order for it, BUT it was not ordered PRN. Correction: pour meds off of the PRN printout sheet not the PYXIS. More careful when reading the PYXIS.

2) 2 units Humulin R to the wrong diabetic patient. My co nurse took the BSG then for some reason: either he communicated to me the wrong patient and/or I assumed the wrong patient. I did repeat the name he told me or at least thought I did. Correction: give medications only off the Meds due report. Wait until he is finished with the report where he writes the BSGs then give the Insulins off of that sheet.

One more, BUT I can't remember it. When I make a mistake I try to rehash it in my mind to find what nursing process broke down. Its not that I failed. Both these errors mentioned seem to me to have been errors lurking in my processing of the medications. It was good that the Insulin error was only for 2 units and for a diabetic patient.

How did the error happen ? What was the piece of the process that was responsible for the error ?

My mantra before I give out meds is to check the armbands on every patient. That is one mistake I just don't want to make. One of our best nurses just gave out the wrong meds to the wrong patient. Bunch of heart pills that the patient should not have received. He assumed he knew the patient.

[htrn]

I always report errors and strongly encourage other nurses to do the same - even if it was as simple as giving Motrin too early. Many nurses are afraid to report errors, afraid of retaliation or repurcussions. Even if the nurse can call the MD and say 'hey, I accidently gave phenergan with that Demerol because no one cleared the labors orders off the profile after the c-section' and he says OK, just write the order. It's still a med error that needs to be reported.

I had a huge error involving pt. ID - a sentinal event. No harm was done, but it was a huge problem. My hospital risk manager and DON came in to talk to me, saw how devastated and upset I was and the RM actually gave me a HUG!! I could very ealisy have been fired, and rightfully so, but the hospital used the incident as an opportunity to create/tweak a procedure to prevent such errors.

I have seen my hospital fix many system errors because a nurse reported the error. The nurses would not report errors if they were afraid of retaliation and then those errors get repeated and repeated. Not good for our patients.

[SmilingBluEyes]

I have to say this:

I have had coworkers and my assistant manger all say they trust me a lot because I DO admit when I screw up.

It's never easy to admit. And that horrible sick feeling in my stomach is something I think anyone who has made an error can relate to. But I have not had my mistakes held against me, ever. I have actually, in reporting that "biggie" I told you about, had some coworkers change how they do things because of it.

That can't be a bad thing.

Now if I had covered it up and hidden it, I would feel bad still----really badly. And if the mistake had been uncovered and I had either lied or omitted, I think there would be huge trust issues on the parts of my coworkers/mgt with me, as well as the physician. She has never treated me poorly or differently because of this, if anything she was VERY nice the next week or so afterward, because she knew how awful I felt and that I did own up as soon as it was discovered there had been a problem caused by me.

I hope never to make a major error like that again----Lord, please no. But if I do, I have to say, I will HAVE to report it. I can't live with the guilt of making an error like that AND covering it up.

You know what I feel worst about? That the patient had to go through what she did (a very rapid csection versus a more relaxed, controlled situation) because of my mistake. Yes, her baby and she were fine, but I feel so badly about any distress I caused that lady. If I saw her today, I would feel the guilt rise up again. I never want to cause harm to a patient or her baby due to any error on my part.

[snowfreeze, BSN, RN]

I report errors even minor. This helps with preventing further errors from happening. I have never felt that I had problems due to reported errors.

[mugwump]

i do report errors but I have to admit I think twice because every error I have reported or has been reported on me I've been disciplined for. It just sucks

[SmilingBluEyes]

I would have issues working in a place that felt punishment/discipline were the only ways to handle error commission. It's been studied and shown that this contributes to non-reporting. And non-reporting means an error is not being examined to see WHY it happened, and more importantly HOW to fix the "system" so it never occurs again. That is a shame. Many errors, esp. med errors are related to system problems, not just nurse-committed mistakes. For the system to be "fixed" we have to KNOW there IS a problem!

Such a shame.

[ns lpn]

I've reported an error on the second day at a new job and I was just sick. I gave a client another clients meds (there are no arm bands), it was the worst feeling in the world when I realized what I had done I got hot, was weak, and nauseated. I fiqured for sure I'd be fired, but I did report it. My first concern was for the client and I would have been okay with lossing the job at that time. Besides accountability being part of nursing, I think hiding mistakes allows errors to continue. We are human and no one is perfect. I did not loose my job, the client was fine, I have never repeated that mistake again and I have never forgotten the feeling I had when it occured. Honestly it took me a while to get over it and I almost left nursing, it was a supervising staff on shift that day who helped me through it. I have been at this job for 4 years now and it has never been held against me.