Dearest Gardengal1:
I would like to start by encouraging you. Every one of us has made a mistake to one extent or another. Consider that errors can be acts of commission and omission. I have forgotten antibiotics on a particularly busy shift in both the ED and L&D. Who's to say that this act of omission is any less devastating to the patient than whatever happened to you. Antibiotics can have a serious impact on patient prognosis in terms of their length of stay, morbidity, and mortality. The main thing is that you own this mistake in the exact manner that you are doing. You reconcile with yourself that you are human and as such, you will err. Unfortunately, there is no way around that. It is really important that you look closely at what happened and determine if this was a failure in the system or if it was a simple human error. For example, if certain "hard-stops" were in place, could the error have been prevented? I have several thoughts around this. If the error was in programming the right rate on the pump, could a "smart pump" have prevented the error by taking the flawed human mathematician out of the equation? If labeling was an issue, could we place the labels in a locale that would make them more accessible? Think long and hard about the exact path you took that led to the error and consider if the system had anything to do with it.
You have been a nurse for a great number of years and have practiced safely so I
sincerely doubt you have a lot of "bad habits." However, this is worth definitely considering. I certainly mean no disrespect, but if you have any habits that you know are not in our patients best interests, this may have been your wake-up call. We all have them and it takes courage and a humble attitude to admit them and move forward. I like to give you an example from my own experience if I may. I have recently moved from practice (though I still work PRN in the ED) to nursing academia. I am uber-passionate about patient safety and healthcare quality and tend to weave that into all my interactions with my students. I once told my students that in our present healthcare environment, it was imperative that items that fall on the floor be thoroughly sanitized or discarded if unable to sanitize. I was working as Team Leader during a typically hectic ED shift and was cleaning one side of a “double room.” The patient in the other room was an elderly confused patient who kept pulling her leads off. Her daughter asked me if I could reconnect her leads. Well, as you already know, the leads were laying on the floor. I picked them up and as I was about to reconnect them, it occurred to me that I was about to do the exact thing that I had told my students they must never do. I sucked it up, pulled out a couple of sanitizing wipes and cleaned the leads prior to replacing them on the patient. Did it take more time, sure, but was it in the patient’s best interest? Absolutely. We carry around funk-factors all over the bottom of our shoes from isolation room to isolation room. We do not wear shoe covers and bacteria like c. diff can survive for months. I have a lot of reservation around ever reusing anything in the patient care environment that cannot be properly sanitized because you cannot “see” many of the bugs that can wreak havoc on the imunnosupressed patient or any hospitalized patient for that manner. IMHO, this is one of the factors that play a significant role in our rampant rate of hospital-acquired infections which have risen to the millions per year! This example may seem small in the grand scheme of things, but we should all remember this one thing, to our patients, every little thing matters.
Being a patient advocate is so difficult, if not impossible, in our present healthcare delivery environment. It means being 100% accountable for what you do and also 100% accountable for what you see other folks doing. Even more challenging is being 100% accountable for doing the right thing every time when we don’t have the time to do it! Seeing a wrong about to happen and not saying something is nearly as negligent as committing the wrong yourself. Another example, how many of you have ever witnessed a nurse push an IV medication through a port that hasn’t first been swabbed with alcohol? I don’t know about you guys, but I see it all the time. IV tubing has the potential of being some of the most germ ridden stuff in the hospital. Patients drag it around everywhere. Bathrooms, outside, etc. We never ever have any business pushing anything through a port unless we have thoroughly “scrubbed the hub.” That doesn’t mean a quick swipe … SCRUB! I have taken to carrying around a pocketful of alcohol wipes and have stopped many-a-nurse dead in their tracks by handing them one. Yes, I have gotten a number of “Well aren’t you Nancy Nurse” looks. However, if we are honest, people DIE from infections they are given in the hospital. Scrubbing the hub can make a difference between life and death for the patient. You’d want it for yourself and for any member of your family so why would we do any less for our patients? I think I know …
I may seem to have digressed a little from the original main idea of the posting but I like to circle back. OP, your offense is NO WORSE than picking something up off the floor and reusing is, failing to scrub the hub, or neglecting to use isolation garb in a patient’s room who has a case of diarrhea which has not yet been diagnosed. I’d like to offer you the opportunity to look at this through global lenses and take a gander at all the ways nurses have fallen short of doing the right thing for their patients. Take for example that my mother had a recent 11-day admission to an oncology floor. During only one shift assessment did a nurse pull out her stethoscope and listen to my mother’s lungs and bowel. My mother was septic and had renal impairment as a result. I’ve never felt more helpless as a family member or nurse. As they began to fluid resuscitate her, her UOP was negligible. She complained of DIB at one point and I had to ask a nurse to listen to her lungs. Help me understand what has happened to our profession?
This posting is not meant to bash nurses because I can’t imagine any profession for which I have a greater respect and affinity. I only mean to draw attention to the fact that we all need a wake-up call to the fact that one offense is no greater than another. We have all been set up for failure in the very system that is supposed to support and champion safe patient care. It is nearly impossible to not make an error in our present system and it is a miracle that you have gone this long without one! We are all asked to do more than we are humanly capable of doing with little back-up support to assist during the times that we are struggling or busy with another patient. Even in locales that have addressed the nurse-to-patient ratio, which are few and far between, have experienced less than satisfactory quality outcomes because, and this is merely my personal hypothesis, they have been remiss to address the fall-out of the burnout syndrome. We can fix the ratios through legislative action (if we will all get onboard); however, we will need to heal a very wounded profession through a variety of creative methodologies if we are to rid our profession of all the bad habits and attitudes that have resulted from centuries of disenfranchisement.
OP! If I were in your presence, I would squeeze the life out of you with a big old hug. I know one thing for certain, you will absolutely learn from this mistake and I can almost guarantee that you will never make it again. I hope that you will use this experience to help prevent other nurses from making this exact same mistake. You can bet that if you made it, a number of others have too and also a number of others will make it in the future. Use this experience as an opportunity to reach out to your nursing peers in the interest of protecting our vulnerable patients.
Warm Regards,
Tabitha
