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  1. Forever a New Nurse

    Feeling terrible about mistake

    Thank you all for your responses, story sharing, and support
  2. Forever a New Nurse

    Feeling terrible about mistake

    Hi I'm writing today to get support/feedback and mostly to just express my sorrow to others who may understand what I have done. I am a registered nurse of 7 years; 5 years in ICU ( 2 years SICU, 3 years CCU). I feel constantly humbled by this job and as soon as I get semi comfortable I am again brought to my knees. I love doing patient care, but I hate dealing with lines and medications that can easily hurt or kill a patient and feel I am obsessively careful, and double triple check everything. I worry a lot about everything (which is why I have no place in the ICU in the first place) and am always questioning when I will make my exit from bedside due to this constant worry and anxiety when at work. Here is my mistake I need to share: I had a very sick patient on balloon pump with swan. PA pressures were high, wedge high, pt is needing diuresis and cardiac support until more desirable fluid status is reached. B/p low with MAPs in 50's. Swan has no VIP port. Pt is on dopamine and dobutamine running to side port of swan. IVPB are running to PIV. Lasix drip going at 1ml/hr (5mg/hr) to other PIV. PIV with lasix not the best line, considering starting new line, but decided against it b\c pt has swan with many ports. I have never infused anything in the PA (yellow) port before, but honestly did not know you weren't supposed to. I debated whether to use yellow port (PA) or blue port (CVP) and connected the lasix to the yellow port d/t I was not drawing mixed venous gas and could still monitor the waveform while the med was infusing. I actually thought I made a good call, as the yellow port has 3ml saline flush that would help the 1ml/hr lasix trickle in. (I know, terrible terrible terrible call) Day shift came in and I'm grateful it was an experienced nurse who immediately switched the lines and informed me of my error. I feel so dumb for not knowing this, as everyone else I've spoken to seems to know this is a huge 'no no.' Of course I am now obsessively reading articles on it and can't believe I made this error that could have easily hurt or killed this patient. I feel paralyzed by this mistake. Luckily the patient was not harmed and only improved over my shift. It was actually a good shift up until the time I gave report and now I just feel terrible. Crying a lot, hard to get out of bed. Just thinking how the patient was thanking me, so grateful for my care when over the night I was infusing a med directly to her pulmonary artery! Luckily it was only lasix running at very low rate. Also lucky to have been followed by an experienced nurse. I feel so embarrassed and bad for my actions. Will I ever feel experienced in this job? I feel I have to leave bedside care out of fear of making a mistake and becoming a non-functioning human after. Also, knowing that it's going to be a big PSN and I have to face the music that I was the one who did it. I want it to be brought up and blasted for everyone to hear, so no one else makes the same mistake. Though it seems no one else would, as I am the only one who seems to not have known about not infusing meds through the PA port. I feel embarrassed and humbled, it's going to be hard to show up again. It doesn't matter how many times you double, triple check something if you don't know what you are doing is wrong. 5 years in the ICU working with swans and I did not know you are not supposed to infuse meds to the yellow port. WOW!. Thanks for listening.
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