Old nurse, New BSN, MED ERROR

[marace]

I worked over 22 years and five at a big hospital. I hung a bag on a patient and did not follow protocol since our floor was just soo busy; I was in charge, had a preceptee, a new nurse on the floor, five patients myself, two of those were trachs, and an aide that did not show so I was taking VS.

Yeah... sounds stretched too thin.

When It was found it was 3 days later. Other nurses caring for that patient lost their job since they did not check the med hanging.

There were so many things that went wrong:

1. I did not double check with another nurse.

2. I got a 'code' from the pharmacy, they gave everyone the same 'code' that day, so I 3. had grabbed someone else's bag.

4. I put it in my pocket and carried it with me for over an hour, I just couldnt get to the room nor could I get anyone to take time to go in there with me. It was that busy.

5. I put it on the pt's pole in the room so two of us could look at it when we had time.

6. The pump started alarming since the previous bag was empty.

7. I just hooked it up intending on coming back with another to verify and locked the box which had previously been left unlocked by anesthesia. The box was so full of tape residue you could not see into it.

8. My shift was ending, and it was still not done, asked the oncoming nurse to check it with me, she got called to help move a new admit to a bed..

9. I asked another and she got pulled to help again another admit to a new bed.

10. 13 hrs later, I am so exhausted, I just went home.

_________________________________________________________________________

3 days later I get a call at 4 a.m. asking if I remember anything about this person.

I have to wake up and think and then my nightmare starts.

THANK GOD the PATIENT WAS NOT HARMED!!

The doctor was forgiving, saying it was an error and no harm done; pharmacy was freaking and wanting to hang me by my neck... I can't help but think how many med errors I had prevented before with pharmacy, such as finding an ATB bag with heparin as a base. I had admitted it must be me and never tried to lie my way out of it. I asked to take full blame.

Mistakes can happen to anyone.

Hindsight; do not let any institution make you SO busy that you don't even have time to go to the bathroom much less try to take on other's work. I would have been liable if those vital signs were not recorded but much better than making a terrible med error that also resulted in 3 other seasoned nurses to lose their jobs too.

This was 2 years ago and I sometimes cannot sleep when I think about it.

I now do casemanagement to avoid giving meds and this story has now followed me to my new job.

[OCNRN63, RN]

What a terrible situation for all involved. I applaud you for being honesty and not trying to cover over the error or fob it off on someone else. Now you need to forgive yourself for what happened. All of us have made mistakes when caring for patients; it's the risk of working in health care.

Print out your post, read it, and either shred it or burn it, then let it go. Don't let your mistake define you.

[miasmom]

Aww. Tell me a perfect nurse or person. I know you are beating youself more rhan anything. You are human. Find a new job. Different area of nursing.

[DedHedRN]

"NO Harm Done" was the most important words I read in that entire post. No harm done to the pt! OMG, close call, but NO HARM DONE! People make mistakes, and suffer the consequences, but at least you didn't hurt the pt. Sounds like your not the only one to have made mistakes that day, pharmacy giving every pt the same code, the on coming nurses not checking with you, and then the problem extended for three whole days till the mistake was found. But the pt was not harmed. Unfortunate that people lost their jobs, but it was years ago, and you learned from it and have a new job that you cannot make this same mistake in. Maybe you need to seek a counselor to vent with so you can move past this.

[ToothFairy(5)]

At somepoint we have all made a mistake. It speaks highly of you that you took ownership of it. Let it go now. I like what ONCRN63 said. Print it out, then shred & burn it.

[tyvin, BSN, RN]

You tell us how busy you were and how you saved many lives via the pharmacy but I think you still feel guilty over the other person being fired. And what does your BSN have to do with a med error? A nurse got fired due the mistake. You are looking for a bunch of "oh, poor you" and "you did all you could"...if that's the case, why do you still feel so guilty?

Always follow protocol; that's why it's there!

I recommend a therapist...

[jadelpn, LPN, EMT-B]

We all make errors. The intent is not to harm anyone. This shouldn't follow you around from 2 years ago. I think that as your new job in case managment who you work for may allow you to do is to teach part of orientation or a class on this subject, so it doesn't happen to someone else. I would also think you would rock as a risk assessment nurse......

[Biffbradford]

Gotta ask ... what was the bag? D5W w/ 20kcl instead of 0.9n/s? Dobutamine instead of Dopamine?

[Anna Flaxis, BSN, RN]

You made a mistake. The patient was not harmed. You feel terrible and have learned from your mistake. I'll bet you never make the same mistake again.

[Mulan]

"I now do casemanagement to avoid giving meds and this story has now followed me to my new job."

Followed you as in you brought it along with you or someone at the new job brought it up?

[HouTx, BSN, MSN, EdD]

OP, your story is very powerful. As an educator, I think that you could add a lot of value to the dry and routine "medication administration" module that is provided as part of orientation - or as a special topic for a nursing grand rounds. Have you thought about doing this?

[plinytheRN]

I am a new grad and constantly am so scared of making a mistake and hurting someone. Thank you for sharing your story, so much risk is involved in this job. the pace and work load is insane and of course everything falls on the nurse's responsibility, it's a miracle more mistakes don't happen. I can't help but feel that the reason this happened is due to the work environment- not you. When forced to work in those conditions, mistakes are bound to happen. The silver lining is that the patient was not harmed, and you share this story with others to learn from it.