Stressed out - high potential for error in critical care

[questioningnurse]

Hi everyone,

I've worked in the ICU for just over a year, almost 4 years' experience as an RN. 

I've been struggling, especially recently, with fear over the potential to make a mistake at work. This is compounded in the ICU, where even a single, small mistake can threaten a patient's life. What's strange is that this feeling has worsened over the last few months, after I felt I had achieved a feeling of competence (I don't believe one should ever be "comfortable") in the ICU. 

I've had positive feedback from coworkers, preceptors, and management about my performance at work. I have made a work-related mistake in a previous position that resulted in no patient harm, which I reported promptly and managed correctly with the physician and management. However, this anxiety has resurfaced despite no recent errors being made. 

 I mostly love the ICU, I am excited by stressful situations, critical illness, complex situations that require critical thinking, and working closely with physicians. Most importantly, I am deeply fulfilled by helping my patients and their families. But it is such a strong anxiety that it sometimes makes me doubt my career choice.

Wondering if any of you face this same anxiety, even a year or so after being in the ICU? And any suggestions on managing it? 

[JBMmom, MSN, NP]

Anxiety about errors can be a useful tool, because it keeps us from becoming complacent. Paralyzing anxiety can be detrimental because it can keep you from performing at your highest level because of fear. Take your statement that even the smallest mistake can threaten a patient's life. Other than administering a medication to which a patient has an anaphylactic response, or maybe administering a paralytic to a patient not mechanically ventilated, how many small mistakes are truly immediately life threatening? I'm not trying to make light of your concern, and maybe a bunch of people would disagree with my statement that most medications we administer may have an element of danger, but we also have the means to ameliorate most of those effects with other interventions if necessary.  We had a nurse recently run an entire bag of amiodarone over the course of an hour because they hung that instead of the ordered antibiotic. AND it was hung on the wrong patient. And the patient remained stable for the next four days. 

Do you have EMR scanning for all medications? If you are checking your rights and using your scanning system, the potential for errors is greatly decreased. You said you have been given positive feedback about your performance. While medications are an important aspect of ICU care, there are so many more parts, you must be excelling overall in the field. Try to think logically about your fear and realize that you have achieved a level of competence in a challenging area and you are probably right where you should be. Good luck!

[CCU BSN RN]

I've been in ICU about 5 years. I'm still anxious about messing up and killing someone. I'm less anxious about it now that I have some experience under my belt, but you're at a difficult level of experience right now. You're getting more competent, which means you can appreciate how many ways in which a simple error could cause irreparable harm. You likely used to only understand about half of these ways. Sometimes ignorance really can be blissful. 

 

I find it helpful to remind myself that our unit has a very good spirit of teamwork, and any time your patient becomes more critical and starts alarming to high heaven, bleeding profusely, having life-threatening arrhythmias, etc....you wind up with at least a couple of colleagues coming to see what's going on. And if you've missed something, they're pretty good at asking appropriate questions and rapidly determining what you've overlooked or might have messed up, and then helping you fix it. 

 

Also, even though it's not very kind to admit to, I like to remind myself of things my colleagues have messed up before, which often horrify me when I hear about. Because if my colleague bolusing an entire bag of insulin or letting their chest tubes clot off didn't kill the patient....well, patients can be hard to kill sometimes. Even when they're very ill. Your body really WANTS to stay alive. It's full of compensatory mechanisms that allow people to have a heart rate of 30, or a SBP of 60 or a sat of 57% for awhile before they actually croak. That said, sometimes a swift breeze could take your patient out. 

Finally, if you quit and your colleagues are more short-staffed, mistakes will be made and more people will ultimately have poor outcomes. You WILL ultimately make mistakes, whether you're made aware of them or not. We're all human. Just try not to make the same mistakes multiple times. 

To recap: 

1. Mistakes are human, patients would die without the ICU, you're providing a service with a net positive outcome, even with occasional mistakes. 

2. Humans are hard to kill (mostly)

3. A little anxiety is helpful, a lot of anxiety is crippling and deserves therapy and/or meds. 

4. An adverse event is very rarely exclusively YOUR fault- there are many members of the healthcare team, as well as the nursing team. 

[NurseBrittRN]

The more experience you gain, the better you'll feel. 9 years of ICU experience and I'm still concerned about "messing up" or "missing something" but this helps to make you a conscientious nurse. 

My first year in ICU I was very overwhelmed. By the end of year 2 I started to feel confident. There's no way you're going to know everything and you're not expected to. What's important is to learn as you go. If I get a diagnosis, medication, treatment etc I'm not familiar with, I start Googling immediately and ask other nurses, docs, pharm, etc questions to get familiar with it.