Syringe Disaster

[LibraNurse27]

Hi all, I am having a mental health crisis and had to take a few weeks off work to stabilize, and feel I'm not able to accurately evaluate the seriousness of situations in my current state. I changed jobs 9 months ago and had trouble finding a psychiatrist with my new insurance, and ran out of my meds for bipolar 1. After a few days off meds I felt disoriented and experienced trouble focusing, even some visual hallucinations.

These symptoms became increasingly worse yesterday during a busy shift with short staffing. A pre-op nurse asked me to give 5000 units heparin SQ and show her how because she hadn't given a sub q since nursing school. I have given heparin hundreds of times. But I felt so out of it, I could barely figure out how to draw it up. I used a 1ml syringe that didn't have a leur lock instead of a 3ml leur lock syringe. When I gave the injection some of the heparin went in but then the syringe disconnected from the needle and the rest spilled onto the bed! The other nurse saw it but didn't say anything. The OR team was rushing her so they could bring the pt in. I told my charge nurse and she said I didn't need to tell the surgeon.

Apparently the pt had no history of blood clots but had once had a weird phlebitis of a vein in his hand that resolved on its own, all labs for a clotting disorder negative. She said anesthesia didn't think he needed heparin but surgeon did. I wanted to let the surgeon know but I was being called back to PACU because another patient was getting up unassisted and another coming out of OR with no nurse available. By the time those things were settled the heparin patient was in the OR. The rest of the shift I could barely function because I was sick with anxiety on top of my bipolar symptoms. I finished the shift but avoided giving any meds. Today I went to the ER and got my meds plus time off to find a psychiatrist. Do you think I am horrible for not telling the surgeon? I am seriously considering resigning even if I'm able to re-stabilize on medication. I don't want to be a danger to patients or become someone who doesn't own up to my mistakes. Thank you so much for reading this long post.

[JBMmom, MSN, NP]

I think you've already gotten some good feedback and hope you are less concerned about what happened.

I just wanted to add that I am very happy to hear that you prioritized your health to make sure you get the help that you need. Taking care of yourself is the most important thing you can do right now and I wish you all the best in feeling better soon. 

Edited to add that recently I've found more syringes where the needle connection is loose. I've gotten into the habit of hand tightening every syringe needle when I first open the package and before I draw up any medication because I had a similar thing happen. 

[LibraNurse27, BSN, RN]

Thank you @JBMmom ! Ah I'm sorry you've had some faulty syringes too! I know there are a lot of issues with supply chains, so maybe hospitals and clinics are not getting their usual supplies. Good idea to hand tighten every syringe. I will start doing that if I go back to work. I may have to take myself out of the game and go on temporary disability or get a nursing job that requires less focus, speed, and multi tasking.

There will be an opportunity for full time in pre op at the eye surgery center I work at per diem. Then I would just need to do the same thing on repeat: questionnaire, eye drops, and IV. It will be a large pay cut, but if my doctors think it's for the best I will do it. And making less money may help me quality for help buying a home here in the Bay Area since things are so expensive! Trying to stay positive. Thank you for your kind reply. 

[nursel56]

I agree with the others. All the best. ((Libra))

 

[Lynker, LPN]

I can completely relate, as I have s/sx of bipolar type 1 and I'm on meds for it. I've also had a similar heparin incident. Just know that you can only do your best. We all make mistakes. It's a shame we have to go into work during our low times. You're not alone. ❤️

[LibraNurse27, BSN, RN]

1 hour ago, Lynker said:

You're not alone

 

1 hour ago, nursel56 said:

All the best

Thank you for your well wishes! I met with a psychiatrist and looks like I'll be on FMLA for awhile, then see what to do next. I agree it's not great to go to work during times of instability, and I'm grateful to be able to take time off for my own health and for the safety of my patients. = )

[londonflo]

On 8/23/2021 at 2:40 PM, LibraNurse27 said:

for full time in pre op at the eye surgery center I work at per diem. Then I would just need to do the same thing on repeat: questionnaire, eye drops, and IV.

I had cataracts extracted last Summer and I really felt less anxious when I had the second one removed. The routine is impeccable, drops in at certain times, confirmation of health details, it was set up so well. It turned out I knew my nurses, both times from when teaching. One in 1990s and one in 2000. Their talk got me so relaxed. I could hear them speaking with other patients and a similar manner was evident. It is really set up for every patient's routine is done easily. You know the surgeon can only do one case at a time. You will do great.  

[LibraNurse27, BSN, RN]

@londonflo thank you for the encouraging! I hope I will be able to work there. I had to cancel the 2 shifts I signed up for in Sept because I can't work anywhere while on state disability. I guess all the money they took from my checks for the last 8 years is what I'll be paid with for the next few weeks! LOL 

[VivaLasViejas, ASN, RN]

 You have my sympathies, Libra. I have Bipolar I as well and it stole my life’s work from me at an age (55) when retirement shouldn’t have been on the agenda for another 11 years. I was on my last day of floor nursing when I gave a patient two heparin shots, which while it didn’t harm him it drove a stake through the heart of my career. I’ve been on Social Security Disability for over six years now, unable to work at all due to memory issues brought about by repeated manic episodes and the use of hardcore antipsychotics.

 I’m doing very well moodwise, haven’t had a major depression episode in four years and it’s been even longer since my last full-blown manic phase. I’m also self-aware and know my limitations. It’s too late for me (I’m 62 and not in good physical health), but it sounds to me like you’ve still got some gas in the tank. So, take your leave, use the time to get stabilized, and see what else might be out there. You acknowledge that you weren’t in your right mind when you made your mistake, and that is admirable. The priority now is to get your BP under control so you can make good decisions in the future, especially when it comes to your career. I hope it goes well for you, but don’t be ashamed if it is indeed time to walk away.

I wish you well. Please keep us posted as to how you’re doing.

[10GaugeNeedles, BSN]

Seems weird that the surgical team is anticoagulating with sub q heparin (not exactly an acute treatment). Yeah you should have done your stuff, documented accurately, and directed the pre op nurse to inform the surgical team so they can decide what to do (my guess is he would just give a second dose of he was real uptight about it but he should always know if there's a deviation from what he thinks it's going on). That was her med to give was it not? In this situation, I would likely consider her the best resource about what to say to whom, but clearly state in the computer a partial dose was given and so and so observed it. But don't feel bad. You'll never put a push on needle to a syringe loosely ever again right!? ?. Mistakes happen. Mistakes are how humans learn best. And not all mistakes are created equal. Early on, I once sprayed the ceiling with Dilaudid cause I didn't know how that stupid snap in syringe cartridge thing worked. LOL. You'll be fine. 

[LibraNurse27, BSN, RN]

10 hours ago, VivaLasViejas said:

The priority now is to get your BP under control so you can make good decisions in the future, especially when it comes to your career. I hope it goes well for you, but don’t be ashamed if it is indeed time to walk away.

 

Thank you so much for the advice ? I will definitely not go back until if and when I am competent to do so. It sucks because as you said I feel the disease has taken my career and my skills. I was a really good nurse up until a few months ago. It does seem the disorder itself as well as the medications affect memory and concentration over time. I am glad to hear you had a successful career, retired when you knew it was time and you are doing well! Thank you for sharing!

2 hours ago, 10GaugeNeedles said:

Seems weird that the surgical team is anticoagulating with sub q heparin

If I was thinking clearly I would have questioned the order. Most patients who are truly high risk don't get anything in pre-op due to risk of intra-op bleeding, and go home on aspirin or lovenox. Sub q heparin duration of action is 8-12 hours so wouldn't do much as most clots don't develop during or immediately after surgery. The pre-op nurse didn't think it was a big deal and didn't want to notify because she was so rushed. Due to my mental state I couldn't figure out what to do, which is what scares me. I should have asked her to notify or asked someone to help me in PACU so I could do it.

I'm glad the mistake is not likely to cause harm and gave me the wake up call that I need to step away for now. It's a hard to admit but it's necessary. As for your dilaudid syringe disaster... yikes! LOL! I know exactly which syringes you're talking about!! I've see people do exactly what you did! Thank you for sharing ?

[SmilingBluEyes]

I sure do wish you the best. You have been through it! And I suspect you are really berating yourself even more than you let on here. Please, please take care of yourself and continue with gentle self-care. I hope you feel better after posting this and getting some of the kind responses here.

Take good care and go back only when you feel truly ready.

[LibraNurse27, BSN, RN]

20 minutes ago, SmilingBluEyes said:

I sure do wish you the best. You have been through it! And I suspect you are really berating yourself even more than you let on here. Please, please take care of yourself and continue with gentle self-care. I hope you feel better after posting this and getting some of the kind responses here.

Take good care and go back only when you feel truly ready.

Thank you!! Yes I feel SO guilty about not reporting my error, and I still can’t really understand how I couldn’t figure out what to do. I also have anemia so I used that as an excuse and asked a nice coworker if all my patients from Friday are OK (we do post op calls). I just said I was out of it from anemia, and she said everyone is fine. I want to tell the full truth about why I was out of it, but my doctor advised me not to due to the stigma =( if I end up not being able to return I think I will be truthful about why though. Everyone I work with is so nice and it doesn’t feel good to be not all the way truthful. Thanks for your kind reply and your encouragement!