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...
Specializes in criticalcare, nursing administration.
how beautifully written, and how painful to experience. I too have been there. What I laud you for is your ability to accept the responsibility for your part AND to recognize that systems errors are at the heart of many of these unfortunate experiences. I eventually became a manager and director during my 45 year career. MY pain and my error made patient safety a priority in my practice. I NEVER placed blame, just looked at what failed in the system. My mantra became " Safe, quality care delivered with passion and compassion". As it should have, the safety came first. Good luck through the resolution of this, and don't worry about those finger pointers. There but for the grace of God go they......
This is every nurse's worst nightmare, and you are approaching it intelligently and realistically. Still, the heartache is awful. Years ago, I gave an overdose of Epi to a 10 month old baby. I had a fever of 102, obviously should not have been at work (long story), and my angel was right there on my shoulder. The parents were so understanding, no charges were filed against me, and I got very, very lucky. I choose to look at the incident optimistically...it could have been so much worse. It sounds like you were a respected nurse before this incident, and that will go a long way towards continued respect, especially the way you are handling this with so much dignity. And, your respect for yourself will help you heal. My heart goes out to you, and I hope this is all resolved soon. You will go on to help so many more people, remember that.
Been there , done that. I'm a nurse in the Netherlands. It happened to me in 2003. It's your worst nightmare. But after a while you notice that no one judges you, not even my employer. And yes , I've been through three hours of interrogation by two detectives and by the healthinspector. And after two years I Had to appear before the medicaljudge ofthe medicalcourt. It wassen't easy. But it made me a better nurse, I'm a very proud nurse now, appreciated and respected by my colleages. My patients respect and trust me. The guild will vanish along the years. And I teach studentnurces about it at nursingschool and fellownurses at my work. Just take the time to process this. For now it feels like you're in a nightmare , but it will get better. Keep up the good work.
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.
I think it is not appropriate at this time. Not because of me but because it's an uncertain situation.
Someday, I will post the details because it is instructive. Gotta wait till the dust settles.
I wish this website and stories like this were around when I first became a nurse. Making a mistake, med error, poor decision, errors of omission happen to all of us eventually. We do support you.
Specializes in criticalcare, nursing administration.
agree with music in my heart. DON'T share details here until all is resolved. DO share your pain, and WE will share our support. BTW, my ( system) error resulted in a patient death. New equipment, no inservice, four of us in the room, but I was the one closest to the ventilator... Can STILL tell you the patient's name AND feel your pain...Amazingly , the doctors in the unit were VERY supportive. They told me that ALL of them had been, or would be there some day. Those are the risks in the increasingly complex world of patient care.
hard to have a feeling or comment as you never say what the mistake is. obviously it was not a big one as you are still working and you say your co workers are compassionate. I would doubt that. you are probably talked about behind your back because that is what nurses do. I have been a nurse a long long time. anyone who makes a mistake is labeled, as I believe you are. again, not knowing what you did is hard to even comment on. med error? dropped a patient. etc. to write an intelligent article you shoud just state the case. what happened, what the out come was for you and the patient. what did you learn and how would you prevent this in the future.
hard to have a feeling or comment as you never say what the mistake is. obviously it was not a big one as you are still working and you say your co workers are compassionate. I would doubt that. you are probably talked about behind your back because that is what nurses do. I have been a nurse a long long time. anyone who makes a mistake is labeled, as I believe you are. again, not knowing what you did is hard to even comment on. med error? dropped a patient. etc. to write an intelligent article you shoud just state the case. what happened, what the out come was for you and the patient. what did you learn and how would you prevent this in the future.
The OP said it was uncertain; meaning, if he is working, he MAY not end up in his current situation. Also, there may be identifiers that he may not want to share at this time; the Internet is not so anonymous as one thinks.
Personally, the OP can take all the time he needs.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
hard to have a feeling or comment as you never say what the mistake is. obviously it was not a big one as you are still working and you say your co workers are compassionate. I would doubt that. you are probably talked about behind your back because that is what nurses do. I have been a nurse a long long time. anyone who makes a mistake is labeled, as I believe you are. again, not knowing what you did is hard to even comment on. med error? dropped a patient. etc. to write an intelligent article you shoud just state the case. what happened, what the out come was for you and the patient. what did you learn and how would you prevent this in the future.
I think you missed the point of the article....that everyone is vulnerable to mistakes. I disagree that anyone who makes a mistake is labeled...labeled as what? Human?
We don't know if the OP is still working...does it matter? clearly this event has had a major impact on him/her enough so to write a post about their experience. Knowing the OP and their posting history s/he are sincere, smart, and a good nurse.
NONE of us are exempt from mistakes and they can be made at any time. Those who believe they are exempt are fooling the self into a false sense of security! Mistakes are always just around the corner for a of us.
I don't need to know WHAT the mistake is for I think the lesson here is we are all vulnerable to mistakes. A word of encouragement and awareness is important for each and everyone of us at the bedside to remember that we are all equally vulnerable and never forget the basics.
luvRNs, BSN, MSN, RN
76 Posts
how beautifully written, and how painful to experience. I too have been there. What I laud you for is your ability to accept the responsibility for your part AND to recognize that systems errors are at the heart of many of these unfortunate experiences. I eventually became a manager and director during my 45 year career. MY pain and my error made patient safety a priority in my practice. I NEVER placed blame, just looked at what failed in the system. My mantra became " Safe, quality care delivered with passion and compassion". As it should have, the safety came first. Good luck through the resolution of this, and don't worry about those finger pointers. There but for the grace of God go they......