Mistakes

[studog12, BSN]

Hi All,

I know that there are already other threads about this topic, but I decided to start one just so I could get some direct feedback.

So, I am on orientation in an ICU at a nationally known hospital, and I am also a new grad. Recently (but not too recently), I made a couple of mistakes and I guess I just need to vent, as I have been discouraged and a bit worried. My first mistake (while on my current orientation) involved turning one of my patient's sedation off to do a breathing trial, and instead of staying at the bedside and monitoring how he did, I left to go check on my other patient, for some reason not thinking that I needed to stay at the bedside. I had never done a breathing trial by myself, just been shown one by one of my day preceptors. The patient had restraints and couldn't pull out his breathing tube or any lines, but I still felt bad because it certainly would have made him uncomfortable had my night preceptor not caught it. My other mistake was I hung potassium as a secondary line with heparin, not thinking that, duh, if I hang the potassium with heparin, the heparin infusion will stop, which is a big deal, as this is a high risk med. Another mistake I made while in school was during preceptorship, and I am embarrassed to even talk about this one. I went to hang some magnesium, as I had hung many IV medications before and felt comfortable doing so. However, I had not worked with these particular IV pumps before, and as I was setting up the line and priming it, I didn't realize that I had not installed it in the pump, and I had already hooked it up to the patient. I began to program the pump and kept wondering why it wasn't working, so I checked the roller clamp to make sure there wasn't an issue there, and eventually I just went to get my preceptor for help, trying to be safe and do the right thing. However, by the time we returned to the room, the magnesium had already infused into the patient as a bolus...I guess when I adjusted the roller clamp I either didn't check the drip chamber or I did and it wasn't dripping--but then started to after I walked away. Talk about almost having a heart attack. The patient ended up being fine, and I honestly have no idea why I didn't think in that moment, "Duh, you have to install the line into the pump." I was tired and working the day shift, which is common, but something that one just has to work through.

Anyway, I have to be brutally honest about all of this because I just want some honest and candid feedback about it. The thing is, I am a VERY, VERY conscientious person, even to a fault and to the point of perfectionism. I would NEVER want to harm a patient, and I make patient safety my number one priority. I have caught safety hazards from other nurses as I began to care for my patient after report, and yet, I still screwed up, and I just feel so stupid. How could I make such a mistake, particularly the one with the mag bolus? I mean, why did I just not "think" in that moment? I have gone over it in my head a thousand times and still can't come up with an explanation, other than I was sleep deprived, or I was rushed and felt intimidated working with a tough preceptor (referring to my most recent mistakes) and got too ahead of myself. Anyway, that mistake with the mag happened while I was in school, and I have moved on. But my recent mistakes have resurrected anxious feelings, and I am just uneasy because I don't want to make another serious mistake in the future, especially if I am not realizing I am doing it, you know? I will be the first to admit that I have a tendency to space out in terms of my attention span, but I recognize this and am ALWAYS present in the moment when at my job, ESPECIALLY when right in the middle of patient care.

To wrap up, if it came down to it I would quit my job in a heartbeat if I knew that my personality or way of doing things or whatever was going to be a liability to any of my patients. I was drawn to nursing and ICU nursing for all the right reasons, I still think--I enjoy continuous and in depth learning, am very detail oriented, enjoy quality nurse-patient interaction with 1-3 patients, and, though cliche, am driven by helping people, particularly on such an intimate level. I guess I just need some encouragement or some honest input about whether I am cut out for this profession. I still believe in myself, as I know and have read about other nurses making mistakes, even serious ones that have had major, even fatal repercussions for patients. But I just needed to put my thoughts and feelings out there and get some feedback.

Thank you so much for taking the time to read this. I know it is a repetitive topic but very important nonetheless.

Yours,

E-Stu

[Double-Helix, BSN, RN]

We have all made mistakes. Any nurse that tells you that he/she has not made a mistake is either lying or never caught the error. Your feelings are normal. None of us get up in the morning (or evening) and go to work intending to hurt a patient. It is an unfortunate part of being human. What is important is that you learn from each mistake. I bet you will never hook up a line to a patient until after you have set it up on the pump. I bet you will always check that you are infusing medications through compatible lines. And I bet you will always remember to have someone with your intubated patient who is having a breathing trial. You are doing the right things. You are working in a complex and fast paced environment, and you are learning. That you feel this way is a good thing. It will make you a better clinician, and make your patients safer.

If your facility offers an Employee Assistance Program, you might consider checking out the support resources that they offer. You may find them helpful as you cope with these mistakes and move forward in your practice.

[Been there,done that, ASN, RN]

During orientation, your actions are monitored by your preceptor, and are THEIR responsibility.

Where was your preceptor during the breathing trial and the magnesium and potassium infusions?

It is the preceptor's responsibility to TEACH you the procedure and protocol.

[studog12, BSN]

Thank you so much for your kind reply. It really means a lot. I wish this were not such a taboo topic and that everyone would be more empowered to be more open and honest. And yes, I can tell you I will never make the same mistakes again. I have had a step-wise routine for hooking up IV lines ever since, look through all of my IVs to see which ones can have secondaries (and if none can I grab an extra pump or channel), and I will most certainly be at the bedside the next time I do a breathing trial.

[studog12, BSN]

@Been there, done that, thank you for your reply. Well, for the magnesium instance my preceptor asked if I was comfortable hanging it, and I told her I was, and I really meant it. I had hung enough IV meds to be comfortable enough doing it on my own, and I would never do something I wasn't comfortable with without help present. I was just unfamiliar with the pump, was working my way through the process, and then when I was having difficulty then proceeded to ask for help. The lesson there was I should have had her come in with me once I realized I was unfamiliar with the pump. For the potassium/heparin instance, my preceptor was in the room with me, and to be honest I don't remember if I started to hang it and then she informed me of the error, or if it had been hanging for a short time and then she noticed it and informed me. The reason I don't remember was because it was brought up after the fact and not by her, but my supervisor who had solicited her feedback. For the breathing trial instance, my preceptor should have been in there with me. I think he basically said something along the lines of, "Ok, so you need to do this, this, and this" and included in that to-do list was a breathing trial. He didn't ask if I had done one before. And don't get me wrong, I am not averting my own accountability. But I do think it was appropriate for him to make sure I knew the correct protocol and routine, etc. He is a young nurse, though (and a good one), so I can't act as if he has the experience of a seasoned nurse.

Also, in regards to the IVs, going through the process of hanging an IV med was never explained in detail while in school; we just practiced doing it. There was never any critical thinking-type questions like, say, "Why wouldn't you want to hang a secondary with certain primary infusions, such as insulin, heparin, or Levophed?" or "What should you always make sure to do before you hook up an IV line to a patient?" Etc.

[Susie2310]

You have asked for feedback about the errors you have made, and I am not unsympathetic to your situation as you are aware that the patients could have been seriously harmed, but I have some feedback/suggestions to offer you.

Are you using your "Five, Six, Seven (or how ever many is being taught now) Rights for three checks when you prepare and administer medications? Do you look up the medication and know the indications for giving, contraindications, patient assessments before/after giving, lab studies needed, expected effects, side effects, adverse effects and the action to take to remedy the situation, and patient monitoring necessary? With IV medications you need to check compatibility also. If you don't know how to perform basic IV skills that would normally be taught in nursing school you need to ask for help with learning this. It sounds as though you may need to slow down. Patient safety must always come first. Take the time to be a safe nurse. With the magnesium error during clinicals, why wasn't your preceptor supervising you hanging this medication? Had you read the policy and procedure for administration of magnesium? When I was a student we would never have been allowed to give IV medications without our preceptor present, and this would certainly have applied to a medication such as magnesium with a critically ill patient population. As a student and as a new nurse, you do not yet have the knowledge and experience to practice safely unsupervised. Had you read the policy and procedure for administration of potassium and why wasn't your preceptor supervising you hanging it? You are giving high risk medications to critically ill patients.

With the breathing trial, again, had you read the policy and procedure and why wasn't your preceptor supervising you? With any nursing intervention/treatment, again, stop and think, "What do I need to know in order to do this safely and what must I do in order to perform this safely?"

I hope the above is helpful. It is true that everyone makes mistakes, but learning from them and knowing how to do your best to prevent them from happening again, or from making mistakes in future is what is important. It is very important to develop safe practice habits.

[Double-Helix, BSN, RN]

It didn't even register that the magnesium error occurred while you were a nursing student. There is no way you should have been allowed to hang a high-risk electrolyte without supervision. That mistake is entirely on your nursing instructor and the preceptor who allowed you to do that without watching.

[studog12, BSN]

You are probably right, and I have been able to let that go with time. Like I said, recent events have just resurrected past feelings, you know? Thank you.

[studog12, BSN]

@Susie 2310, thank you for your reply. To kind of respond to your response point by point, yes, I definitely check to make sure that I am giving the correct medication and taking the time to look up what I am giving and why it is being given to the patient. In fact, pharmacology is a subject that fades fast if you don't constantly refresh your memory and learn new things. Scanning medications through the computer is a way to make the process a little faster, but I still make sure the computer order matches what I am giving.

In regards to the IV medications, I always check compatibility, too. I would say even at the time I felt comfortable with basic IV skills; this was a blunder I made because, well, I guess I lacked the awareness/knowledge in this instance. So technically I wasn't fully competent. Perhaps you might think that I am not completely competent with these skills, but as far as what I know now, I am competent, and should something come up in the future I will certainly not hesitate to ask about it. I know the "not knowing what you don't know" phenomenon applies here, but IV skills are not complex (not to belittle their importance), and I really do think I know what I need to in order to administer IV medications safely each time I do it. As far as slowing down is concerned, you're right. I am in no rush when giving medications, but there is always a time constraint in nursing, and I think there should be a healthy incentive to pace oneself overall. But in certain situations, such as administering medications, it is crucial to make sure one gets it right rather than try to do to much and compromise patient safety. Probably the number one issue I had with one of my day preceptors was she pushed me to the point where I didn't feel like I could take my time with things because she was always on my tail to be faster. And, quite frankly, it was a miserable learning experience because of it.

With regards to the breathing trial, I confess I did not look up the policy, but I did have it taught to me and I should have asked my preceptor to explain it to me again and to stay nearby should I have needed him. I am working my way to being autonomous, so there is an element of space between us; but I should have asked and made sure he was close by. The magnesium administration follows along the same lines--I just should have consulted with my preceptor when I realized that I had not worked with those pumps before and had her there with me while I hung the mag.

Again, thank you for your feedback and your wisdom. It sounds like you are a detail oriented and very competent nurse.

Ethan