Peer Review questions

[Ddestiny]

I'm sorry this will be long. I am having some questions about the peer review process.

I just finished a 12 week orientation in my hospital's ICU. On my 4th week I had a med error where I incorrectly programed a bolus of propofol for a patient on the vent that was becoming agitated. I thought I was administering it in mgs, when I was really administering it in mgs/kg -- much, much more than what I was trying to give. I found this out when pt's BP decreased, from fairly normal 100-120s/60-70s to the lowest at 79/30s-40s (sorry, I don't have the exact numbers in front of me). The monitor alerted me to the change in VS, so I immediately checked her Propofol and realized that, even though I'd started the bolus several minutes ago (going to have to look back through the whole chart to see exact time frame), the bolus was still infusing. I immediately stopped the propofol and either restarted or increased the pt's pressor (sorry for fuzzy details, it's been 8 weeks, but I do know that I brought the BP back to systolic 100 within 10-15 minutes). Immediately after changing the medications, while waiting for a few minutes to pass to recheck VS, I informed my preceptor. She and I talked about what happened. I had not yet previously given a Propofol bolus but had known that it was an option to do because I had seen her give at least one of my previous patients a bolus of propofol. I thought I knew how to program it in correctly but this situation showed that I obviously did not. I have given several boluses of propofol since then on other patients and have done it correctly, if not hyper-vigilantly.

This happened right before shift change. After stablizing the patient, I told the oncoming nurse what happened and let her know why the Propofol was stopped even though pt was having intermittent agitation. We figured out together how much propofol the patient received and I didn't leave until VS were back WNL. Ultimately there was no long-term poor outcome to the patient but I am completely aware that things could have gone VERY differently.

I was notified that this situation was reported ~3-4 weeks after it occurred (I have no ill will towards the night nurse for reporting it, it was a legitimate error and I learned a lot from it). During one of our standard meetings with my new supervisor and my preceptor, the supervisor asked about it and we told her what happened. Orientation continued on as usual.

Last week I finished out my last week of orientation and met again with my supervisor (preceptor absent due to illness). Towards the end of the ~45 minute meeting she said that she did need me to make a statement for her as the situation will go to Peer Review in a couple months. She told me about how if this situation, upon review, is still considered a Level 3 (standard of care not met with potential harm to patient), then it can go on to the board of nursing. She didn't seem particularly concerned about it, saying she thought the most that would happen either way would be to get assigned further education (which I'd be fine with -- I'm soaking up as much education as I can). She said to make sure to include in my statement that I was on my orientation. She will take the statement and read it for the review board, I am not to be present.

Has anyone else been through this process? Since the mistake happened 2 months ago and I'm aware that the patient is fine and long ago went back home, I have to admit that I'm very nervous for *myself*. I really pride myself on being a thorough, conscientious nurse (though obviously with much to learn in this new setting) and the error itself was quite a wake-up call that has really made me even more careful with new medications, especially boluses. Having my statement read before a review board so much later after I've already made 3-4 months of changes (review is in November) is anxiety-provoking. My supervisor's calm demeanor about this is comforting but it does make me wonder if maybe I'm missing something here -- what is the worst-case scenario here? Should I be notifying a lawyer? I'm so naive to this type of thing, I've known OF the peer review board but never known anyone to openly talk about being a part of the process. Though I logically understand that this is just "a step in the process" to keeping all patients and nurses safe, I'm also in uncharted waters and feel like I'm walking around with the word "unsafe" tattooed on my forehead. *sigh*

Does anyone have any insight?

[Ddestiny, BSN, RN]

Thank you again to everyone for the continued support. I've been "offline" for a few days but wanted to provide a small update. After reading TriciaJ's comment...

Actually, hospitals and units get dinged when there are no errors reported. It's assumed a certain number of errors happen and if none are reported, then they're being covered up. You've given the hospital a chance to show TPTB that it's on top of things. They owe you one.

....it helped me to change my perspective a little. I had fallen into a bit of a "what is going to happen to me" anxiety and was having difficulty seeing past it. But this somehow helped to....I don't know, "normalize" the process a little. It made me feel comfortable enough to reach out to a former boss who is not only an experienced nursing supervisor (love my current one to death but it is a new role for her, not much more experience in it than I have in the ICU) but also has a J.D. and has worked in nursing Risk Management at my same hospital, so she's quite familiar with this process. She walked me through the specifics of the different standards of care (and agreed that my error would be a Standard of Care 3 -- standard of care met with real or reasonable potential for harm to patient). Anything that is a Standard of Care 3 or 4 (4 being drug diversion, extreme recklessness or intentional harm to patient) have to be reported to the BON. It's a long, drawn-out process but for things that are Standards of Care 3 the expectation is that any "punishment" will be an assignment of further education (i.e. 6 hours of CEUs r/t sedation, 4 hours of education by someone within the company, etc). There is not a risk to the license like there is with Standards of Care 4 situations, and thus no lawyer is necessary. She offered to read over my statement (without patient identifiers of course) prior to having it submitted to my boss to go to the review board.

I can't speak to the process for other states (I'm in Kansas), but...well, this is something I can live with. I made a mistake, one that did have the potential for long-lasting harm (my former boss did say that making the BP go into high 70s/40s is still technically "harm" even though we, in the ICU, are fairly accustomed to these numbers). I have no problem with additional education; as I've said I'm seeking it out already; going to an expensive symposium in Critical Care and Trauma next month, I make it a goal to listen to ICU lectures online at least 3 of my 4 days off, I'm starting the ECCO (Essentials of Critical Care Orientation) online education this week, and have attended/am scheduled to attend all of the additional ICU required classes (Basic dysrhythmias, 12 Lead EKG, CRRT, Hemodynamics, IABP, ACLS, etc). Education is my friend! lol

Thank you again for the kind words. It really helps to hear others say "it's okay to make a mistake". Obviously we want to avoid them at all cost but eventually something will slip through. I didn't realize how "common place" this process was, and you all really helped me to prepare to do this with a level head and eyes wide open. =)

[Jory, MSN, APRN, CNM]

I don't have any first- or secondhand experience with this, but I'm sorry this is happening. By taking a punitive approach, they are discouraging self-reporting. Why would a nurse intentionally jeopardize her livelihood?

You will never ever make this mistake again. Propofol is a relatively "good" med to make an error with, since it is so short-acting. I have had patients' BP drop to similar levels even with proper administration; they had either come in dehydrated or were more sensitive to the drug than typical. But the BP recovers quickly (assuming that THE cause was the drug). Heck my own BP dropped to 60/30 after getting an epidural, recovering with an extra 1L bolus. You didn't harm the patient, and you clearly learned from this.

I agree with this entirely. I actually want to give this new nurse a high five for catching the error and investigating the cause for the change in her patient. Many would have blown it off because it was a "Patient on the vent"...AND you reported it and took full responsiblity.

We all make mistakes and this is what nursing is all about.

A big middle finger to your manager for blowing this out of proportion and making you think your nursing license is at risk. You were in orientation and frankly, at four weeks? They should have been supervising you more closely anyway.

I don't think a peer review is necessary. You are new, you make a mistake, the equipment was new...no review necessary.

Nobody loses their licenses or even gets dinged for a heartfelt error that occurs ONE time. The BON is probably going to push back on the hospital for not utilizing better training on the equipment.

Do not stress over this.

[JKL33]

You were in orientation and frankly, at four weeks? They should have been supervising you more closely anyway.

I don't think a peer review is necessary. You are new, you make a mistake, the equipment was new...no review necessary.

Agree. OP, the way you handled this is a testament to your integrity and I wouldn't encourage anyone to do other than what you did.

At the same time I think it is absolutely rotten and despicable to allow a brand new nurse who is on orientation to shoulder this. They messed up big time, IMO. Unless an orientee goes off the rails and does a move like this after being told not to touch any drips without direct supervision, the facility needs to send themselves to "peer review." I understand a need to convey that this was a serious error, but the way they are handling this is devoid of ethics.

[Ddestiny, BSN, RN]

I thought I'd provide an update for anyone interested in hearing the end of the story.

Peer Review was a couple days ago. I provided my statement to my nursing manager (much like the one above but with more details), who read it in front of the group. It sounds like the general consensus of the room was "well, I bet she'll never make that mistake again" (Oh, how right they are!) and it was labeled a Standard of Care Two!! So, no further action.

My NM told me and, like me, was just so glad to have it all done. She told me she'd heard a lot of good things about me from patients and colleagues. It's so good to get this monkey off my back.

Also helpful was that, while reviewing the pt chart to get the specific details for my statement, I was able to see that she was extubated ~16 hours after the incident and transferred up to the floor the next day. I knew that she had been fine but hadn't taken care of her since then; just come in to check on her the next morning while she was still intubated. So glad that my major learning experience, though anxiety-provoking and definitely cause for my stomach to drop at the time, is done and with no lingering effects to the patient.

Thank you all for your support while I was going through this. The camaraderie of nursing colleagues means so much. =)

[jennylee321]

Glad to see this turned out okay! Good luck with your future ICU career

[JKL33]

That is wonderful news! Now it's full steam ahead in having your mind free to absorb new(er) nurse knowledge!

Nice of you to update.

Take care ~