Please Help! Major ERROR

Nurses General Nursing

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Hi Everyone,

This is my first time posting here and hope I can get advice. I'm a first year RN in Florida who made a huge mistake.

Here's the situation.....

During shift change I took an over the phone order from a doctor for a patient. I mentioned the new order to the nurse and moved on. At that time I was giving report to the oncoming nurse and dealing with getting a new patient at that same time from the ED. Well....I ended up writing the order in the wrong chart not even realizing it. I finished report, helped get the new patient settled and then went home. The next week when I came back to work I find out that I had wrote the order in the wrong chart and that patient had been recieving an antibiotic that was intended for another patient. To make matters worse the patient had a rash from it but is OK.

So......what really sucks is that if I had been able to check it after it had been transcribed by the secretary I would have caught it but since it was change of shift the on-coming nurse would have never know it was on the wrong patient and she check off on it.

I take full responsibilty for what happened--I feel so horrible I can't stand it!! I haven't slept in days and seriously doubting my choice as a nurse. There is sooooo much liability as a nurse. I love being a nurse but on my floor most patients are very sick and need much attention. Are ratio is 5:1 and you get pulled in many directions all day long by patients and familys!

Anyways. I'm going to call my manager because I'm not sure if she even knows what happened yet. Any Advice? Will I lose my job?

Thanks.

Specializes in Med Surg, Ortho.

We learn by the mistakes we make, right? I don't mean to downplay your situation, but try not to let this bother you that bad, it's okay, every turned out okay. It doesn't mean you won't make a good nurse, in fact, you'll be a better nurse because of it.

Do you have an organizational paper brain that you use? I will post a link at the bottom of this page of an organized paper that you can take a look at. On the back side of the page, I draw columns for each patient I have. I label my columns with the room number and place patient labels at the bottom of these columns. If I get a telephone order, I will write it on the back of this page in my column for that particular patient. I also write PRN meds or any other pertinent info, such as lab results, etc. Being more organized will help you a lot. And when you go to transcribe or write an order, just double and triple check.....look at the name, look at the chart your writing in, match names and do that 2-3 times. Like going through the house 2-3 times making sure you turned every thing off before you leave. I don't know if you're like that or not, but I am. It's called OCD. LOL

I won't even label a lab spec away from the bedside......even though I know what my pts name is, I ask them there name when I'm labeling my lab tubes at there bedside while I'm looking at the label. They look at me like I'm crazy, but it's habit I've gotten myself in to. But can you imagine what kind of mistake it could be labeling a wrong lab tube for a different patient??......oh my gosh, that's a nightmare of mine. I'm so careful with this as well as my medication.

I made a pretty significant error once before.......I gave contrast to somebody that had a high creatinine level. Every thing turned out okay, but man, I was so scared. I felt like I ruined this persons kidneys. I'm much more careful. All these types of mistakes, we learn from.

You'll be fine. It's all part of being a new nurse. Almost every nurse I know has made errors, it's just part of the learning process. Take care and get some sleep. You are a good nurse! PS......I think you NM will understand, I don't think you should worry about your job. Just explain to her what you've learned from this.

REPORT SHEET -----

Look on the second page...post #15. This is a very good report sheet you can use. It will hold info up to 6 patients. You can tweak it as you like. Draw your columns on the back and get organized, it will help so much.

https://allnurses.com/first-year-after/report-sheet-148952-page2.html#post3875120

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Specializes in Emergency, Cardiac, PAT/SPU, Urgent Care.

This mistake is one of the exact reasons why telephone orders should no longer be used! Especially in this day and age with all the technology/computerized systems, etc. It would be so much easier for a doctor/NP/PA just to plug the order into a computer program from home or from the office, that way many transcription errors could be avoided. Even if they could fax the order it would help to prevent errors.

I used to hate, HATE taking telephone orders in the ED, because it wasn't just one order, it was usually a whole list of orders - plus all of the patient's meds which I was relying on the patient to be giving me the correct info about without a med list or prescription bottles! I also used to hate doing this for another nurse's patient if I knew absolutely nothing about the patient (one order, not a big deal - but whole admission orders? UGH - scary!).

Yes, please do not continue to beat yourself up over this - the important thing is that neither patient was hurt, right? Hopefully, this will help your institution to realize that eliminating TOs would help reduce errors, and maybe a policy change will come of it after risk management reviews it. I hope that everything will turn out to be fine with your job - you did the most important thing you could have, and that was owning up to the mistake. We all make them, and we all learn from them. They make us better nurses in the end. Best wishes.

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MD should have checked and signed order within 24 hours for a phone order. If it is not signed b then and the other nurses continued to give it it is not just your error. MAR should have been checked every shift by oncoming nurse, so several nurses should have found an unsigned order.

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Specializes in OR,ICU.

i actually have ocd which i have found to be a job asset as a nurse.really ,i mean it. i am what would be called a "checker" and when your icu patient has 7 infusions going this can really help.i always thought it gave me an advantage over other nurses.the more i had to "check" the happier i was.and if you don't have ocd now after a few years you will develop it.i actually dispute the "d" as i don't consider it a disorder for me.:lol2:

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Specializes in critical care, PACU.

I think it's great you took responsibility but also think that maybe there should be a new policy where md's cant give phone orders during shift change. Or at least maybe the next time this happens, you can ask the md to call you back after shift change so you can actually put your full attention to the task. Or better yet, ask the md to put it into the comp him/herself since you are giving report.

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As a supervisor, I'm wondering how this fell through so many cracks. How did other nurses not question the new antibiotic? Why didn't the MD check the orders within 24 hours? How did the pharmacy not question the new order? How did infection control not question the order?

You were only a part of the error. The fact that you noticed it at all, seems to be the good news here. Don't be so spazed. You are now a professional nurse, not a hysterical school girl. Patients, staff, families and your own family and friends will appreciate your expertise much more when you are calm and in control of your emotions. Your husband does not deserve to be driven nuts. He is hoping for you to be happy and satisfied with the career you just spent a fortune getting. As an experienced nurse, I can tell you that getting worked up and bringing emotional trash home is a very negative and personally destructive thing to do. It is, by far, the most difficult part of nursing that I faced. It breaks my heart to see my young nurses succumb to it.

It is possible that you may face termination. It's a shame, if you do. But if that is the mentality of your institution, it's better to find out now and move on, anyway. Why work in a sloppy and unsupportive environment?

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HeatwaveRN,

I can't really tell you either what happened. I'm suprised it was missed for more then 1 day also and why either doctor for either pt didn't notice that they were getting it and not getting it. They both were not on antibiotics. However, I am never taking a telephone order during shift change again as there is usually too much going on at that time!!

Scary, isn't it, that a doctor makes rounds daily (presumably) on his or her hospitalized pt and doesn't see that the pt is now on something he didn't order. Also, the doc who gave the TO should have sought out the chart of that pt to co-sign the TO the very next time he was in the hospital, but he didn't, apparently.

Is the person who was supposed to get the abx getting it?

I see this as part of a system error. You should not have to take phone orders in a non-emergency ever and especially not take phone orders (or verbal orders) at shift change.

Nor should you be receiving a new patient at shift change. Your managers and dept. heads need to make this stop. If they won't, you need to just refuse to accept patients at shift change. You can do this without much ado by being unavailable to take report for a small window of time before you have to give report and count.

I'd write it up as an incident that someone sent you a patient at such a terrible time. Did they even give you report? Did you know the patient would be arriving at that time? Did you know the patient had arrived?

How long does shift change take? Probably at least 20 minutes if you have to count and give report. This should be a time when no new patients/transfers arrive, as you can't immediately go see them. Furthermore, since you were going to be leaving, how could you be expected to actually receive this patient and be responsible to do anything for or with this patient? This transfer should have gone to the oncoming nurse, AFTER she got report and counted.

I'm glad the recipient suffered only a rash - which is still an adverse reaction but at least not anything more serious.

Don't be too hard on yourself, as these things happen and this really was not all your wrongdoing. But you must limit your exposure and protect your patients in the future from this avoidable type of error. Just don't answer the phone any more, even if it's a doctor. Tell the secretary or whoever is calling you to the phone that you are in report and the caller can speak to the charge nurse or call back in 30 minutes and ask for the new nurse and give that nurse's name, since you will be gone. And seriously, if it's not an emergency, tell the person to fax the order. Have your fax # handy. make sure it's right. you will need your boss' support to make this happen without the caller taking your hide off. Or hand the phone to the oncoming nurse and let her take the call, since she will be having the patient and you are, for all intents and purposes, off duty.

And they need to make the doctors fax orders in, not phone them in, in non-emergency cases.

BTW, you should stop broadcasting your mistake. You've already owned up to it. The catty nurses you work with will just have to eat someone else up because you have said enough and are not going to say any more about it in their hearing. Right?

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As a supervisor, I'm wondering how this fell through so many cracks. How did other nurses not question the new antibiotic? Why didn't the MD check the orders within 24 hours? How did the pharmacy not question the new order? How did infection control not question the order?

You were only a part of the error. The fact that you noticed it at all, seems to be the good news here. Don't be so spazed. You are now a professional nurse, not a hysterical school girl. Patients, staff, families and your own family and friends will appreciate your expertise much more when you are calm and in control of your emotions. Your husband does not deserve to be driven nuts. He is hoping for you to be happy and satisfied with the career you just spent a fortune getting. As an experienced nurse, I can tell you that getting worked up and bringing emotional trash home is a very negative and personally destructive thing to do. It is, by far, the most difficult part of nursing that I faced. It breaks my heart to see my young nurses succumb to it.

It is possible that you may face termination. It's a shame, if you do. But if that is the mentality of your institution, it's better to find out now and move on, anyway. Why work in a sloppy and unsupportive environment?

If you do face termination, get a lawyer and sue because you will be being made the scapegoat for the errors of many people, as mentioned by rlaffn and me and others. Don't take all the blame. Fight back.

As for your husband, yeah, it's best, in general, to try to not burden him, although you do need somewhere to open up. don't be too specific here on the internet. Maybe talk to a TRUSTED friend or relative who will never share the story with anyone.

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Specializes in Pyschiatry/Behavioral (Inpatient).

Tips that helped me as a new grad:

Transcribe orders in a quiet place. Focus on completing one task at a time and don't let things like a phone ringing or a call light distract you. Finish what you were doing and then tackle something else. I still have to remind myself of this from time to time, that way I don't have to be like "Wait... what is it I was going to do?" after I got interrupted.

Hopefully your facility does not look down upon self-reporting and is not focused on punishing for errors. They should look at the problem, not the person, and figure out why it happened. This is not your fault, it is a failure of a system. Do not blame yourself. Look up the "Swiss Cheese" model for errors/sentinel events. There are many people and many events that have to happen for an error to occur.

I take phone orders all the time because I work weekends when there is not a doctor around. I repeat back to them what I think I heard them say and then they say yes or they clarify it. Then I write it down immediately on a blank order sheet I have in front of me, write the patient's name on it, then fax it to the pharmacy.

Once you get a routine down and avoid certain pitfalls like distractions, things will go more smoothly. I hope this helps.

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Wow, Thanks everyone for all the great advice.

First, I did talk to my manager. She was great! She told me to first stop worrying about it and mistakes do happen and from this we learn. She had not even heard about what happen yet. I don't think anyone had reported it yet (or was planning too)

At our facility MD's have 48 hours to sign orders!! I guess because of the weekend? I never really thought anything of it until now! When I'm back at work though I am curious to see if an MD did sign off on the order I put in the wrong chart.

bigbub3000--The person that was suppose to get the abx was being discharged the next day. I would imagine the doctor came in a continued a prescription for them. Also, it's not uncommon at all for us to recieve a patient during shift change (crazy, huh?) Usually we have 5 patients. I could have 3-4 discharges and depending on the timing I could get 1 admission about lunch time and 2 admissions at or close to shift change. I know that charge nurse tries to stagger patients out but it usually doesn't work out. Usually, I will get these patients at admission is because I think the previous unit or ED does not want to give report off again or get a new patient so close to the end of the day which is how we get overloaded. I definetely agree there should be a policy or something where you cannot get a patient 30 min before or after shift change so those patients can get the attention they need.

Everyday I go in and decide what I can do to be a better nurse. I think this is just one of those things that I will definetely be more conscious of.

Also, when I do read back orders I always read back the drug, etc. We are switching over to computer charting/orders and still have papers charts too. So I had the right patient on the screen but not the chart! :uhoh3:

Unfortunatly this slipped through a lot of holes. I catch mistakes all the time too. I wonder how many really do never get caught??

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Usually, I will get these patients at admission is because I think the previous unit or ED does not want to give report off again or get a new patient so close to the end of the day which is how we get overloaded. I definetely agree there should be a policy or something where you cannot get a patient 30 min before or after shift change so those patients can get the attention they need.

QFT (Quoted For Truth!)

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Specializes in Management, Emergency, Psych, Med Surg.

You need to discuss this with your manager as soon as you can. You have taken responsibility for your error. I hope that the doctor has been informed so that the medication is now being given to the correct patient. Don't beat yourself up because from now on you will double check yourself over and over. We all do after we make an error and we all make one at one point or another. It is important to learn from this and to make sure to double check yourself. I almost made the same mistake yesterday. We do this when we get in a hurry and sometimes we just HAVE to slow down because otherwise we might really do harm to someone.

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