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...
It could be any one of us. I've made a couple of "mild" med errors over the years--but in reality, no med error is "mild."
As nurses, we are required to be incredibly fast, and incredibly accurate. It's so frightening sometimes, knowing that at any one moment, today might be the day I make a horrible error or omission and really hurt someone.
Big hugs to you. This is an unfortunate reminder that today could be any of our "days." So, thank you for putting this story out there. I wish you the best in walking through the aftermath, and for the best possible outcome.
I have resigned myself to the fact that if we stay nurses for long enough, we will all take a turn at being "that" nurse. Be as kind to yourself during this difficult time in your career.
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.
THIS...my self punishment was WAY harsher, it had my hackles up longer than I care to admit; but then again, it made me a better nurse and help me adjust my nursing practice for the better.
music in my heart, first off I am so sorry. i applaud you for recognizing your role in the error and showing integrity. any nurse who says "i'm perfect" or "i've never made an error" is either lying or so oblivious that s/he doesn't even recognize the error. you are clearly holding yourself to a high standard and that too should be applauded by all of us.
try not to feel like you need to wear a scarlet letter. we are human beings and make mistakes in the face of high pt ratios, acuity, and technology. you did not intend to hurt anyone. please know that I am sending you a hug, and i know you'll forgive yourself for this soon.
For what it's worth, you're a nurse I've developed a lot of respect for over the past months of reading posts. Your integrity speaks volumes. These things can really happen to anyone. Thank you for sharing your experience; I'm sure that wasn't easy. Take care of yourself!
I will be learning from this too. I, as many, have made small errors over the years. I will be hyper vigilant when I return to work tomorrow. God Bless you ♪♫ in my ♥.
If I could impart one thing to all who read this: Slow down, slow down, slow down... even when seconds count... slow down... even when being exhorted by an MD that you respect... slow down, slow down, slow down... and in that final second before you do your thing... slow down, think one last time, call out your intention, pause... and then... go...
First of all I would like to say that I am sorry you have found yourself in this position. There is not one of us that goes into work thinking "I don't care if I do something that harms someone today." Any single one of us no matter how many precautions we take could find ourselves in this same position. If anyone reading this thread is thinking it could never could happen to me because x,y,z, please know it can. It really and truly can. "There but for the Grace of God go I!!!"
I applaud your choice of words. Involved. Perfect choice to describe what happened. Too often I see "messed up" "did something stupid" "my fault" etc. to describe an error. We should all be modifying our speech to take the blame, shame, and anxiety away from ourselves. You can mourn your part in the error for sure, but without adequately looking at the system that allowed the error to happen, nothing is done to prevent or reduce errors from occurring in the future. Punitive or blaming language is a barrier to open discussion in my opinion.
So now you are one of "those" nurses. One of "those" nurses who despite their best efforts, despite countless hours of added education most often done on your own time and dime, conscientious effort to adhere to best practice, and striving everyday to provide excellent care.......made an error anyway. You are human and we cannot be 100% accurate at all times. There are so many demands on our time. Nursing is multi tasking to the nth degree. Coworkers, families, physicians, etc. all interupt us without thought and it breaks our train of thought. Or in the case of an emergency we need to switch gears immediately and again our train of thought is broken. So easy to forget something, misread something, overlook something, grab the wrong med, miss an important value, etc.
Your feelings are normal. Your confidence will be shaken and it will take some time before this isn't always in the back of your head at work. Please repeat to yourself over and over again "I am human" "I do my best" that is all anyone can ever ask of you.
I am very encouraged to hear your colleagues are supporting you and I hope that continues. Surround yourself with family and friends who care for you and will support you while you work through this. Take some time off if need be.
Finally I truly hope you do find the non punitive environment that EVERY EXPERT on error reduction supports. If you do not find this to be the case I would encourage to take steps to protect yourself as soon as possible. If you have malpractice insurance you could start there, they may be able to guide you in terms of resources.
Guttercat, ASN, RN
1,353 Posts
Oh goodness.
It could be any one of us. I've made a couple of "mild" med errors over the years--but in reality, no med error is "mild."
As nurses, we are required to be incredibly fast, and incredibly accurate. It's so frightening sometimes, knowing that at any one moment, today might be the day I make a horrible error or omission and really hurt someone.
Big hugs to you. This is an unfortunate reminder that today could be any of our "days." So, thank you for putting this story out there. I wish you the best in walking through the aftermath, and for the best possible outcome.