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...

[nrsang97, BSN, RN]

I am so sorry you were involved in an error. You are being too hard on yourself. I hope you find peace. I have been involved in some med errors. One caused the pt to get a 3% drip because we had a complicated DDAVP order. I felt bad.

[cardiaccath456]

Thank you for sharing this. I hope everything works out ok for all parties involved. As a new grad, I really appreciate you taking the time to share this. I will remember this going forward!

[newohiorn, BSN, RN, EMT-P]

Many of us have been there. Many of us have been lucky enough to have only near misses. As you have said, learning from it is key but the other thing I try to do with any mistakes or near misses I am involved with is share it with others so they too can learn from my mistakes. I am not suggesting you share it here--just telling what I have done in the past. At least one mistake took me three days to even tell my husband and years before I shared it with a colleague because I was a newer nurse and also felt shame and humiliation. I have since shared the story a number of times when I am watching someone like you struggle with an error. Learn but don't punish yourself--we are only human.

[AOx1]

I often hear lay people complain about medical errors, bad doctors, bad nurses,etc. I don't deny that of course there are incompetent people in every field. However, I think that what gets lost in the rhetoric is the good provider who simply makes a mistake. I know of no job in any field over the years that I have done flawlessly. Nursing is no exception. I fail my patients on a regular basis. Some days, I do everything "right," meet the highest priority needs, and still leave a patient who is not critical, but who just wanted someone to listen, with their needs unmet. I see the same patients repeatedly that are unmoved by education or caring, deep in their addiction, they continue to do harm to themselves. They fail themselves. I fail too. I sometimes see the job as a series of tasks to survive and not an art, even after all these years. I've questioned my decisions in a code, where I did everything by the book but it wasn't enough. I made a med error that scared me senseless shortly after licensure.

I don't want the perfect nurse. That nurse doesn't exist except in their own mind. That nurse is scary and doesn't even recognize his or her own errors, large or small. Bring me the flawed nurse, who cares enough to anguish over a mistake, who cares enough to reportt it and fix it, whatever the consequences. Our job is high stakes. Sometimes, the innocent, both the nurse and the patient, are ground up in the gears of this machine we call healthcare. Please do the useful thing, to keep looking at root cause like you are doing, while avoiding the hurtful (self-blame, guilt). We need the good, honest, flawed nurses in this profession.

[maire, ASN, RN]

Came to say what IrishIzRN did, and I am pleased to hear that your co-workers are holding you up, rather than yanking you down. Keep your chin up!

[SnowbirdRN]

I love your thought process here. That alone shows the positive effort you put into your work and other peoples' lives. You're an amazing nurse just by being able to grow from this experience. Kudos!

[bikerbabe13]

I found your article heartfelt, and honest. As a student nurse, it important to keep this issue in the forefront of our minds before we head out into the world. I appreciate the fact that you took ownership, and have a code of ethics that some do not (unfortunately). The support is all around you....take if needed. Hugs to you. Take care.

[NurseLaurie1966]

I've been there. Associated, but not directly involved. Death. Videotaped depositions. Not easy, esp when it was in regards to a dear, excellent veteran nurse. It broke her heart & spirit. Thankful to have suffered with her, and learned the value of read it slowly, double & triple check. Question. Verify. Check again. Statistics show it is "Destined to happen to every nurse", given enough time & experiences. Feeling your pain.

[0.adamantite]

Thank you for sharing your story. We as nurses need to rally around each other. It could happen to any one of us. When I was a newer nurse, another newer nurse made a HUGE error that went to the courts I believe. I just kept thinking that it could have easily been me. I never judge.

Please take care of yourself and get some follow-up counseling. I firmly believe that we are the "2nd victim" of a medical error and that PTSD for nurses is real.

[BrandonLPN, LPN]

Good for you for having the courage and integrity to share this. It gets tiresome, that game we nurses play where we pretend we're perfect and that only "bad" nurses make serious errors.

I've always said, nurses who claim they've never made a med error are either lying or not paying close enough attention.

Best wishes for the best possible outcome for all involved.

[twss2323]

I lurk on these boards a lot more than I post and I know you frequent here. You're one of the members who I see all the time and respect. I'm so sorry to hear this, I hope you don't punish yourself too bad and all involved turn out okay in the end. Sending plenty of good vibes your way!

Im just a student, but I'm gonna share a little story I will always remember. Brand new clinical rotation for second semester, I go to get a set of vitals on my patient. This floor used the disposable blood pressure cuffs and I had never used one before. So I put it on my patient and start the blood pressure and it's inflating the wrong way. I'm so confused trying to figure out why it isn't working and the patient's wife goes "Honey, I think you put it on backwards". Mortified, I realized she was right and I was tripping over my words in embarrassment. Then the patient tells me "If you never make a mistake, you'll never learn anything... so make mistakes, you'll be a better person for it".

Clearly a medical error is far more serious than putting a blood pressure cuff on wrong, however, either way, I think it's sound advice. Clearly you've learned from this and you're gonna be a better person because of it :)

[Mr. Murse]

To the OP, do you mind sharing what happened? I'm not asking to shame you or anything like that, but rather to learn from it. If it happened to you then it can happen again, but maybe hearing another person's story of their error will at least help some of us prevent that particular one.