Nursing 20 years/MED ERROR
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It was a bad day, on top of my plantar fasciitis, being in charge, people calling in like usual on a Sunday Morning (though never held responsible), I had a 12 hour shift in front of me. I took Vital signs for the Nurses to help out, I also carried a load of 5 patients. We had 3 admissions on our small ENT floor immediately in the morning. At the end of shift, when we are bombarded with admission and their dismissals from PACU and ER, There was an epidural line that was near empty. I could have ignored it but I wanted to be the 'good' nurse that doesn't leave empty IV bags etc for the next shift. I got my code from Pharmacy as the new bag was being sent. It took a long time. It got crazy when it arrived from the Tube system (same one all day),using the code I got from the pharmacist. I put it in my pocket, asked each of the three nurses to double check it with me, they were scrambling and couldn't find time. I was scrambling to accept 2 new patients myself to the floor. I ached, I hurt, I could hardly walk. The clear lexite box the med was in was covered with tape residue and you could not visualize what was in it. The lock was supposed to be locked by protocol and it was held shut by a rubber band. She had been on our floor for a few days. I went and got the key out of Pixis and was interrupted 3 x by others needing help and a family member in the room. I remember looking at the bag.. and I remember nothing. I don't even recall the label. I hooked it up, set the pump, locked it and walked away. I had put up Heparin. a sentinal event. It did not harm her, but she had no pain relief. I got a call the next morning at 5 a.m. from a nurse who found it. Everyone was absolutely in a panic and frantic. I don't blame them. I was in shock. I broke protocol.
I admitted everything. I did not attempt to hide it or skirt around it. I was honest. But in thinking about it I wanted to help the hospital from this ever happening again.
1. The lexite box was not openly visible to contents. (I was told it was my responsibilty to clean the box off to ensure contents were visible) Secondly, the box was never locked according to protocol for 3 days. (Probably to assist in visualizing contents.) The anesthesia nurse did not even check the box.
2. I did not follow protocol, 2 person check was not done.
3. Pharmacist gave the same code to everyone that day for tube system, resulting in a chance for a med error, which happened.
4. Nurses were too busy to assist each other, staffing inadequate.
5. Interruptions
6. Continued practice of admitting patients to the floor during/before report time causes extreme disruption and broken reports. 6:30 -7:30 am and the same, PM.
In the meeting in the next 2 days, where the event was discussed with my $56/mo Union present, I was offered resignation. I also had my name blackballed from the other hospitals for 6 months. I was labeled and unemployed. In shock, I sat in my office getting denials and turndowns continually. I had been previously nominated for awards twice for being a wonderful nurse. This mistake took me down. I understand 3 other nurses were let go in the process and one pharmacist. Because of me.
I had a mental health professional call me to discuss it. I was angry at myself and angry at the system. The patient was failed by me. I was failed by me, the hospital, my coworkers. I beat myself up. Gained 70 pounds. I lost a lot in this; good pay, seniority, friends, respect. It was a very rough time.
In two months I found employment and it was slower, way slower, and I had time to review events. I never stopped saying it was my own fault. I gained 70 pounds.
I met another fellow nurse from another state, similar event. He was given an option to take a med course through the hospital to correct and educate. He was very thankful this was offered to him and he totally understood where I was coming from. He said I did the right thing: I was honest. Because of this; I never lost my license but they did threaten to do so. The process is to be examined, not to punish anyone but to see where the errors were made and enforce how to prevent. People make mistakes. My problem is I know what was right, what was to be done correctly and I put my coworkers ahead of patient safety.
Now they have scanners for medications. A totally different process on epidurals. But those of us involved are gone. I know I learned my lesson. It still haunts me 10 years later.