Made the dumbest mistake last night!

  1. (This is a long rambling vent, forgive me).So I've worked as a nurse on our LDRP floor for almost 5 years (just so we're all aware I should have known better). We are super short staffed right now because we have 3 full timers on our day shift out on FMLA so that's pretty substantial amount of shifts open. Basically almost every day of the month is available to work. I went a little crazy and signed up for tons of extra shifts because I was available and had no good reason not too. I didn't think it would be as draining as it had been, and I certainly didn't see it making me so exhausted I made stupid mistakes.

    Yesterday I went in for just a half shift, noon to 1800, and I truly felt like I was running on fumes. I've worked 36 hours of overtime in the last week . I picked up a postpartum mag patient who had a vaginal delivery the night before and was due to have her mag shut off at 2000 but was otherwise stable. I also got a 2 day post op cs who had delivered a 36 weeker the night before and was feeding poorly and required much more attention. For some reason it never clicked "mag patient= not normal post partum vag delivery". I went in and did my assessment and vitals on her and baby and never did Q1 hour vitals on her the rest of the shift. On a mag patient. WHAT THE HECK? I was in there, I was doing stuff in the room, just not the vitals. You know, that important part of the care of the patient on a high alert med. So I give report and go home and get a call about an hour later wondering if I just didn't chart them because it had been 6 hours since her last bp was recorded. My mind was so toast that I was still not getting it. And then it clicked. I was immediately sick to my stomach. The charge nurse was understanding that I made a mistake and reassured me that no harm was done to the patient, they had shut the mag off by that point and her pressures were fine, but obviously she had to do an incident report. Also the physician was quite unhappy. I had seen her before I left and knew she was in a mood so I'm sure she was bad mouthing me and I'll just assume all of the staff knows by this point.

    Its so scary to me that I could totally miss a huge aspect of care on a patient that I so commonly take care of. I still can't figure out how it never clicked. Not only that but it's incredibly embarrassing, I feel like the unit idiot. I'm torn between being glad it was that OB that discovered the mistake (she's catty and will talk smack about anybody if she's in a bad mood....which is always) and wishing it was one of the more laid back OBs (I think I actually would feel worse if they thought I was incompetent.). I just keep replaying my day over and over in my head and can't stop. I called the charge nurse back and asked her to take me off of the upcoming extra shifts I signed up for and she agreed it was probably best. I didn't even eat dinner last night. I came home and slept for 12 hours straight. But of course woke up with that feeling of 'oh crap. That happened yesterday.' Ugh!

    TL;DR: did Q1 hour vitals Q6 on a post partum mag patient and now don't want to show my face at work ever again.
  2. Visit linzjane88 profile page

    About linzjane88

    Joined: Dec '09; Posts: 270; Likes: 647
    Nurse!; from US


  3. by   klone
    Everyone makes mistakes. No harm came to the patient. It's a lesson learned, both as a reminder of Mag protocol, as well as about not over-scheduling yourself to the point of exhaustion. Try not to beat yourself up too hard, and do realize that most everyone else will have forgotten all about it by the time you go back to work for your next shift.

    And trust me, that's not even CLOSE to the dumbest mistake I've seen.
  4. by   linzjane88
    Thanks for the kind words

    Yeah this had definitely reinforced both of those points for me. I don't think I've ever felt this out of sorts before. Even after sleeping so long last night I feel utterly exhausted. I won't be doing this again!
    It also really reinforces to me not to get complacent with our orders and protocols and just go on auto pilot doing what we've always done (or not even that in this case!). Just yesterday we discovered that our order sets call for pit to continue running at 20/hr for the duration of mag administration. It was a new grad that pointed it out to the rest of us, and sure enough, there it was tucked in the protocol. Nobody knows when that changed and she was the first to catch it....and the only one that's been doing it. Anyway, many lessons learned.

    And hopefully the burning embarrassment will fade soon.
  5. by   CrunchRN
    Too much OT. You need more rest to be your best.
  6. by   linzjane88
    Maybe with all this overtime money I can retire and move to another country and never show my face on my floor again. Ha!
  7. by   Surfandnurse
    Quote from linzjane88
    Maybe with all this overtime money I can retire and move to another country and never show my face on my floor again. Ha!
    Indonesia!! You can easily live on 30$/day including a decent accommodation! After you've saved up about $30-$40,000 and sold your house.......
    Spin the globe & start trotting!

    It doesn't mean your a bad nurse! It just means you don't have to slave away, stressing yourself out for a bunch of American conveniences that no one even needs. You can live luxuriously in Indonesia for as long as u need to hit the refresh button, & with your experience you would never have ANY trouble finding employment when u were ready again!
    Cheers to quitting ✈️⛵️
  8. by   dlcj
    Shhhhh.....! Stop.

    Like others have said, no harm came to the patient. Yes, something COULD have happened. But nothing did. All is well.

    Except for the excessive self-flagellation. I'll bet the charge agreed that you shouldn't work extra shifts right now because you need the rest--NOT because you are a bad nurse.

    Every single one of us has missed something or failed to do something ordered. It is a known hazard of being a human being, and don't think the organization doesn't realize that. Missing Q1 VS is apparently easy to do, so this can also be chalked up to system failure.

    I once missed the significance of an already-tachycardic patient (had been in 130s since admission) jumping to 150s for 2 hours before the charge found it and we worked to correct it. Did I feel like absolute crap? Of course I did. But my manager said to me--and she was absolutely right--"You'll never do that again." She didn't mean it as a rebuke; she just meant I learned this hard lesson really well.

    So stop beating yourself up--it won't help you. Go back to work, hold your head up, do your work, and I'll bet that you become the most conscientious q1h vs nurse they've ever seen.

    You're a good nurse. We need you. Back on the horse.
  9. by   Nurse Beth
    The best way to deal with shame is to accept yourself as not perfect.....fallible-capable of making mistakes.
    You can't change what happened, but you can choose to hold your head high and move forward with grace.
  10. by   PinkNBlue
    Oh girl, don't beat yourself up. Seriously. You realize what you should have done, the patient is ok and it made you aware that rest is very important to ensure safe patient care. It could have been a much worse mistake, especially running on fumes. As for people talking about you... unfortunately on our units, with the ridiculous amounts of estrogen and women who have nothing better to talk about, it may be the topic for now. But it'll fade soon. And any nurse should realize that this could happen to any of us, at any time. Go back and be the awesome nurse you are.
  11. by   jodyangel
    Vitals every hour? So the mag patient gets no sleep.
  12. by   PDees
    Does your unit not have the monitors that you can automatically set to go off hourly?

    We all make mistakes. We learn and move on.

    I made my first med error a few weeks ago. Gave a newborn the flu shot instead of hep b. They look identical and were (they since moved them) next to each other in the pyxis and I gave it before scanning it. Baby was fine thank goodness.