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.

[applewhitern, BSN, RN]

Yes, we all make mistakes, but people die because of it. Please, everybody, follow protocol, no matter how busy you are.

[chrisrn24]

If it is two years later and this still haunts you you need help. It was a med error. Nobody was harmed.

[gonzo1, ASN, RN]

I too made a med error, fortunately no harm was done. But it happened because I tried to take on too much. I was in a new ER job and they kept giving me all the boarders (ICU) and I had a med I didn't know how to give. I asked the other staff and they said they didn't know. I asked pharmacy and they told me wrong.

I left that job because things were so disorganized and I knew I would be in trouble again if I stayed. I was paranoid about giving meds for a long time after that. But I learned/reinforced a couple of very important things

1. Never give a med that seems like too much. In this case I gave 3 bags, one after the other. Should have given 1 every 4 hours.

2. It is better to look lazy or stupid and keep asking until you feel you have a full answer to any med question.

3. If you work in a place where people treat the new people like ****, leave.

4. Never take on more than you know is safe. Even if it means you lose your job. Better to lose a job than kill a person.

5. Sometimes pharmacy gives you the wrong information.

6. It is always better to fess up. This was a case where I could have completely hid what happened. But karma scares me.

7. Education is the great equalizer. I left ER and went to ICU in order to learn how to take care of ICU pts.

I had a new job very quickly, but I was really gun shy for a long time. Turns out I like ICU and don't miss the ER at all.

[NotMyProblem MSN, ASN, BSN, MSN, LPN, RN]

Back in the day when I was a new nursing STUDENT, a simple 'hello, how are you' to the medication nurse was practically a firing offense. Under NO circumstances was anyone to talk to the nurse passing meds. I think they were on to something back then.

Now, we ALL can think of something that we mistakenly did wrong that, when brought to mind, causes us to hang our heads in regret. We can only do the best we can with all that is now being piled on one individual and pray that today is not the day we make a mistake.

[Nurse_cox]

I worked in a hospital that was just as disorganized as the one you described. I worked on the floor for 3 years, then their ER for 2 years. I can't believe I stayed there as long as I did. It was so dangerous, stressful, and uncaring towards the patients. Please don't be so hard on yourself.

[vintagemother, BSN, CNA, LVN, RN]

As a soon to be new grad, I thank you for sharing this story. I will take it to heart and learn from it!

[SassyRN_972]

Bottom line: no harm was done. You owned up to it, probably wrote an incident report and informed the doctor. This was a systems error and they should really try to improve the circumstances that led you to make this mistake. It was really disappointing that they fired the other nurses. I have MANY times caught the pharmacists mistakes and just went on with my day because nothing had happened to the patient. Safety is the utmost concern. It shouldn't be a punitive system and we should all work as a team to improve processes.

[LakeEmerald]

Thank you for your honesty. Trust that you have helped many nurses who read this post. This really spoke to me because we move fast in our ER to keep traffic flowing. I felt your pressure as I was reading your post. I know what that feels like. So sorry you are hurting after 2 years. I'm glad you are working and I hope you are happy. God bless.

[norlns24]

Okay, as a beginning RN student..I'm curious... how common is it for an RN to be instantly fired over a mistake like this?

If you have a perfect record, and are an otherwise good employee (no complaints from co-workers or pts and always dependable) etc. and then after 5 years make 1 dosing/ med error, is it standard or common to just be fired like that?

I'm not defending laziness or carelessness, but as others have pointed out, everyone makes mistakes. Is there no internal review, or hearing...just poof, fired? That to me seems harsh. I realize pt well-being is on the line. I'm not saying there should be no consequences for these types of events...but automatic firing just seems counter-productive. Living under a constant fear of making a mistake and being fired is probably not the best environment conducive to avoiding errors, if that makes sense.

[Scliff]

Sounds like a typical day in healthcare.....sighhh. I'm sorry to hear you continue to bear the burden of responsibility. As a "seasoned" nurse work ethics and accountability have been instilled in you, great qualities! However, it was a "series of events", wherein does the pharmacy, facility, QI/QA's responsibility fall? The pharmacy administered/supplied a medication inapropriately labeled, the facility was aware of the work environment in regards to staffing and patient load, and QI/QA apparently did not provide daily review, otherwise the staffing issue would have been identified and the pharmacys error would have been discovered. Had those been addressed the "series of events" leading up to your mistake could have been prevented. The termination of the other nurses, were they directly related to the same patient and IV bag?

The comment posted by someone previously about following policy or protocol.......my question to you is; How many years have you been in nursing and what area?

[marace]

In answer to many questions:

Yes we make mistakes. Do we get fired? Yes. Even with unions. If the hospital deems that an action or mistake cost them money in any way shape or form, such as in this case, this patient had to stay an extra day to be observed, you get terminated. My biggest regret is that the other nurses, who followed me in the following 3 days also were terminated.

The medication was Heparin and I can't tell you how many times I have found ATB with a label slapped on it and find out its the solution the ATB or other med was mixed in. YES it has a RED LABEL on the bag but here we go, in a hurry and hanging meds, everyone too busy to double check with you. My fault? Whole heartedly yes. Follow protocol. Do not waver. 2 sets of eyes are better than one.

My biggest problem now? This story following me to my new job. I get to relive the horror over and over...BUT thanK GOD! the patient is fine; no problems, no residual.

I have seen nurses put on 'detention' meaning they could not make one more error or miss or they are fired. Suddenly everyone looks at that nurse as incompetent, everyone shuns her or him.

Its a sad way we do things. Like I told the counselor, we forgive doctors all the time because they are human and mistakes can happen. They go on and the doctor keeps practicing. The nurse that makes an error? She is supposed to be infallible and no matter what the working conditions, she cannot make an error in medicine, judgement or take time off to be ill. The nurse is judged from all aspects of every medical person around, from pharmacy, Doctors, coworkers, radiation, etc. A mistake can ruin a career by following the days a nurse ever works.This instantly makes you a 'dangerous' person to work with.

[marace]

I got written up once because I had an abcess tooth (From not being able to get a timely appt with a dentist) and I called in sick one hour before my shift started because that's when the pain got bad from this same institution. It stays on your record for a year. I do understand how hard it is to work short handed, I did it all the time. Especially on Sundays when the younger nurses would go out on Saturday night knowing they had to work the next day. Nurses are not particularly very kind to each other in this regard. Probably trickle down effect from how we are all treated in the work place. Expendible. Replaceable.

The ongoing trend now is to hire new grads and get rid of the more expensive seasoned nurses. Quite different from just a few years ago. All it takes is one event of any kind and the seasoned nurse is out the door, a new grad eagerly waiting to walk into those steps. ITs about cost;making nurses work short so money is saved, paying them less and of course, expendibility. The CEOs make a couple million a year, get bonuses as do the managers if they cut budgets. WHo is at stake? you or your family.