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.
