The Face of a Medical Error...

[Music in My Heart]

Well, it's happened.

Despite my best efforts to provide excellent care, I've been involved in a serious error.

I say "involved" rather than "made" not to avoid my role but to recognize that it was a chain of events that led to the error.

I'm sure many people are familiar with the concept of the Swiss cheese model of medical errors... in order for the error to happen, all the holes have to align to provide a path from the patient to the error... and in this case... unfortunately... they did... and the very last hole ran right through... me.

So, now I'm one of 'those' nurses... the ones who are so easy to criticize... to shun... to ridicule... though thankfully, I've thus far been treated with compassion and empathy by those around me.

A whole host of thoughts and emotions accompany the experience... fear, shame, humiliation, self-doubt, frustration, anger... and a few that I cannot even name (I'm just not a wordsmith)

I've no idea of the repercussions though I'm hopeful that all the talk about creating a non-punitive environment in which errors can be explored and preventive measures developed is sincere and that I can play a role in educating our docs and nurses in how to avoid another event like this.

I'm thankful for my colleagues who've listened and encouraged... and who've recognized that I'm not some lame-butt doofus who's carelessly nor mindlessly working on patients... and who've recognized that they could very easily be standing in my shoes.

Still... I feel shame and humiliation... and whatever other nameless emotions accompany having to accept that, despite my best intentions, I have hurt another person who was counting on me to help them... To Hippocrates or whomever, I have to say, "I have done harm." To that patient I would have to say, "You did not receive from me the care that you have a right to expect" and, from the patient's perspective, the reasons don't really matter...

Now, for some perspective... it really could have happened to anyone... it was one of those "seconds-count" emergencies... with sequential system failures, any one of which would have prevented the error-train from ever having arrived at my station... though it did... and my chosen role is to be the person at the end of the line so it's not something I can shirk.

The truth is, though, that despite my strong desire to tuck tail and run... and perhaps the desire among some to demonize me or toss me under the bus...

I am a BETTER nurse today than I was last week - precisely because this has happened... not only regarding the specifics of this event but in ways that will impact every moment of nursing career henceforth.

I am moment-by-moment learning how to live with this new recognition of myself... how to bear the scarlet letter that I've now affixed to my scrub tops.

What does the face of a serious error look like? For me, I simply have to look in the mirror.

Be very careful out there because you never know what you don't know... until you do...

[Delicate Flower]

Thank you for sharing this. Truly, it could happen to any one of us, at any time.

As you said so eloquently, you are better for having experienced it. Someone once explained it to me like this: If you were a patient and had the choice of a nurse who had made a certain severe mistake and one who had not, which nurse would you choose?

No one is perfect, and everyone makes mistakes. The nurse who has already made the severe error may well be the better bet, because he or she is not likely to make the same mistake again.

[klone, MSN, RN]

I absolutely agree with Delicate Flower. For the conscientious nurse, I think it's pretty safe to say that it's a mistake you will never make again.

Be gentle on yourself.

[Elvish, BSN, DNP, RN, NP]

Honey, I agree with the others. I know what it's like to be 'that' nurse that makes a big mistake. Been there. It's hard to forgive yourself, and the self-punishment is way worse than just about any discipline the employer could throw at you.

You did the right thing, you've owned up to your part in it and learned from it. THAT is what good nurses do.

Any nurse who says they've never made a med error either hasn't been a nurse for very long or didn't catch themselves making the error and so don't know any better.

Take care of yourself and forgive yourself. Hugs.

[sweetdreame, BSN, RN]

Don't forget that you are human! Keep your head up! This doesn't change the FACT that you have been a good nurse for the past 4 years and have saved countless lives. Pick yourself up, dust yourself off, and keep on keeping on.

I absolutely love the professionalism and responsibility you have shown by writing this article and by intending to use your experiences to reach out to others.

One of my favorite books involving creating a culture of safety is "Why Hospitals Should Fly" by John Nance. I think it is a must read, and would really help you deal with this situation. Bottom line, good professionals make bad mistakes when things are left up to human error. Good luck friend.

[tarotale]

i am curious of this mistake that you have done. hope you well

[IrishIzCPNP, MSN, RN, APRN, NP]

I applaud you for taking responsibility and acknowledging the mistake.

It isn't about shunning those who make mistakes...the issue is the nurse who can't see the mistake and his/her part in it.

You made a mistake...the key is you acknowledge your role. That is the sign of a good and mature nurse.

[bsyrn, ASN, RN]

Thank you for sharing, I hope they do take the non- punitive route, many more errors would be reported if there was less fear of punishment. Mistakes happen, even to the best nurses, this too shall pass....prayers :)

[amoLucia]

If I could reach out to you I would give you a big hug. Take care of yourself.

[livefully]

Thank you for sharing. I hope those feelings begin to subside soon.

[xoemmylouox, ASN, RN]

If employers went the non-punitive route many more errors would be reported and solutions could be found to stop them from happening again. Good luck and hopefully in time you can forgive yourself.

[motherof3sons]

your integrity alone is something I applaud. Taking ownership of an error takes more guts than those who hide or never admit to them. Excellent nurses are the ones who look past their own "pride " and look out for the patient, own up to it, research why it happened, take any consequences, learn from it and move forward. Be kind to yourself as you move forward. :)