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...

[Esme12, ASN, BSN, RN]

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.

((HUGS) ) My heart hurts for you. It really doesn't mater WHAT happened but that we are ALL vulnerable.

Man, I am there with you in sprint.

[NurseQT]

There is no such thing as the perfect nurse... We are all human and we ALL make mistakes. What makes a nurse excellent is his/her ability to take responsibility for their error and pick themselves up, dust themselves off, and learn from the experience and help guide other nurses from making the same mistake.

You have shown maturity and taken responsibility for your part in an error. Not only that, you show concern and compassion for the patient involved. You are, in my opinion a perfect example of an excellent nurse. Try not to be so hard on yourself, do not brand yourself as "that" nurse, because you have proven to be anything but "that" nurse! ((((Hugs))))

[nurseprnRN, BSN, RN]

{{song in my heart}} Been there, done that, would never wear the tee shirt but I do share it from time to time, even here.

Life will, in fact, go on. Others will forget, except by general example, what happened. You will never forget, though eventually you won't think of it every day, or every week, or every month, or even every year, sooner or later. And forty years later you will still wonder "what if" when it comes back to your mind ... but your life will go on.

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.

It wasn't my intent to write an "article," intelligent or otherwise; it was simply to share my emotions... which is to say, it wasn't for the collective y'all but rather for catharsis for the singular me.

I am still working... and have every expectation that I will continue to do so... though it's not assured... I suppose it will be clearer when I show up for my next scheduled shift. I do expect to be made an example of... not by summarily being terminated but rather by conducting education for our nurses and our docs... but, I do recognize that I could have just killed my nursing career. I don't think so, though...

I do imagine that there are some who are talking behind my back - or will be - but I can say with certainty that there is also some genuine compassion and empathy... based on some unsolicited spontaneous comments and some exceedingly genuine hugs. However, I think that those who will be talking behind my back probably already are or, if newly so, were bound to start at some point. And mostly, I don't give a... yeah, I'll say it... vulgar word for sexual relations...

It's also a little hard to whisper about it behind my back because I've been very forthright about talking about it out in the light... it disempowers the whisperers to a degree.

Anyway, I'm sorry that you felt my post was not well-stated or perhaps worth having read but, as I said, it was mostly to express what's going on inside of me, largely for my own benefit, as I work toward moving forward. I could have done it in a journal but I figured some who populate this board would identify... and it appears that I was correct.

Best...

[Esme12, ASN, BSN, RN]

I've seen a very experienced nurse fall in a charged situation by giving a med that can only be given by the MD. We all understood why she did it but one single nurse in the room hug her out to dry.

She lost her job.

I think at anytime we a vulnerable.

There was a nurse in Seattle that made one fatal mistake she lost her job and license...she committed suicide

https://allnurses.com/nicu-nursing-neonatal/sad-story-all-584375.html

Nurse's suicide highlights twin tragedies of errors - Health - Health care | NBC News

We are all one step away....

[Esme12, ASN, BSN, RN]

It wasn't my intent to write an "article," intelligent or otherwise; it was simply to share my emotions... which is to say, it wasn't for the collective y'all but rather for catharsis for the singular me.

I am still working... and have every expectation that I will continue to do so... though it's not assured... I suppose it will be clearer when I show up for my next scheduled shift. I do expect to be made an example of... not by summarily being terminated but rather by conducting education for our nurses and our docs... but, I do recognize that I could have just killed my nursing career. I don't think so, though...

I do imagine that there are some who are talking behind my back - or will be - but I can say with certainty that there is also some genuine compassion and empathy... based on some unsolicited spontaneous comments and some exceedingly genuine hugs. However, I think that those who will be talking behind my back probably already are or, if newly so, were bound to start at some point. And mostly, I don't give a... yeah, I'll say it... vulgar word for sexual relations...

It's also a little hard to whisper about it behind my back because I've been very forthright about talking about it out in the light... it disempowers the whisperers to a degree.

Anyway, I'm sorry that you felt my post was not well-stated or perhaps worth having read but, as I said, it was mostly to express what's going on inside of me, largely for my own benefit, as I work toward moving forward. I could have done it in a journal but I figured some who populate this board would identify... and it appears that I was correct.

Best...

Power through! It takes courage. You will be fine ((HUGS))

[BrandonLPN, LPN]

If one has the integrity to face these kinds of errors and the wisdom to learn from them, one will eventually emerge from the ordeal a better nurse.

When I was a new grad, I made a transcription error that resulted in a significant medication error. I transcribed an order for haldol on the wrong patient's MAR (literally identical names) and the error wasn't caught until after the wrong patient received the med. I felt more than awful and was humiliated. But it was a hard learnt lesson. I am now widely known at my current facility as being the most accurate nurse when it comes to noting orders and monthly paper MAR changeovers. And I'm an advocate for large, prominent "name alert" stickers on charts of residents with similar names. Med errors aren't made in a vacuum, and, along with personal responsibility, there are always system flaws that need to be addressed in these cases.

It's so important for facilities to make every effort to treat these kinds of errors as opportunities to fix the process rather than simply being punitive .

[livefully]

It wasn't my intent to write an "article," intelligent or otherwise; it was simply to share my emotions... which is to say, it wasn't for the collective y'all but rather for catharsis for the singular me.

I am still working... and have every expectation that I will continue to do so... though it's not assured... I suppose it will be clearer when I show up for my next scheduled shift. I do expect to be made an example of... not by summarily being terminated but rather by conducting education for our nurses and our docs... but, I do recognize that I could have just killed my nursing career. I don't think so, though...

I do imagine that there are some who are talking behind my back - or will be - but I can say with certainty that there is also some genuine compassion and empathy... based on some unsolicited spontaneous comments and some exceedingly genuine hugs. However, I think that those who will be talking behind my back probably already are or, if newly so, were bound to start at some point. And mostly, I don't give a... yeah, I'll say it... vulgar word for sexual relations...

It's also a little hard to whisper about it behind my back because I've been very forthright about talking about it out in the light... it disempowers the whisperers to a degree.

Anyway, I'm sorry that you felt my post was not well-stated or perhaps worth having read but, as I said, it was mostly to express what's going on inside of me, largely for my own benefit, as I work toward moving forward. I could have done it in a journal but I figured some who populate this board would identify... and it appears that I was correct.

Best...

What a gracious response. I admire your forthrightness and courage.

[Blindsided]

You know, one of these posts used the phrase "held you up." Well that brought tears to my eyes, as that is what most every post here has done. This is your place to come for support, and you have mine.

[Cricket183, BSN, RN]

I apologize in advance for the length of this post.

Music in my Heart, my heart goes out to you. You are handling this with grace, dignity, and a tremendous amount of insight. If I could add one thing to your advice to "slow down", it would be to trust your intuition. I believe God speaks to us in that still, small voice. Listen carefully! I have been where you are and it knocks the wind out of your sails. I have actually never talked to anyone about this other than those directly involved in the 7 1/2 years since it happened. It's deeply personal but I feel compelled to share with you. There were many different factors that led up to the medical error but I was the last stop. It's very sobering when you realize that. There were definitely system errors involved but ultimately the blame was on my shoulders. Very humbling to say the least.

I was the charge nurse on a very busy inpatient oncology unit. (I say "was" because I am currently on disability secondary to RSD / CRPS and my RN license is on inactive status. I did not lose my license.) One of my primary duties as the charge nurse was to administer chemotherapy. I was certified by the hospital to administer chemo as well as nationally certified by OCCN.

We had a young patient who had choricarcinoma, a very rare form of cancer that I had never dealt with before. She received a complex chemo regime every couple of weeks. I was not familiar with some of the chemotherapy agents she was treated with. When we received the chemo orders I looked up how to properly administer those agents that I was not familiar with. Why I did not also look up the standard doses of those medications, I will never understand. I still kick myself for not doing so.

It was hospital policy to have two people verify the chemo against the doctor's orders in the patient chart when we received the chemo from pharmacy. Although I do not now recall the specific details, one of the chemotherapy agents required a very complicated dose calculation due to the way the chemo order was written vs. the way the medication was labeled and supplied by pharmacy. When the pharm tech brought me the patient's chemo, I verified the doses and discovered one of the chemos was half the dose of what was ordered. The pharm tech then did her own dose calculation and said that the dose supplied was correct. I recalculated the dose and still felt like it was incorrect. (Just as a note, we used different methods to calculate the dose. I used dimensional analysis while the pharm tech used a different method.) The tech and I "argued". I refused to sign off the chemo. The pharm tech stormed off in a huff and returned shortly thereafter with a very unhappy pharmacist (pharmD). He took me through the dose calculation and stated the chemo was correct as supplied. I recalculated the dose again and still came up with a solution showing that the dose supplied was half the dose ordered. Because of this he brought in the oncology unit manager. She did the dose calculation and came up the same dose as the pharm tech and pharmD. Against my better judgement, I relented and assumed that I needed to go back to school and relearn dose calculations.

It was also hospital policy to have two RNs verify the chemo prior to administration. When I went to give the patient her chemo, I had another RN verify the dose with me. She came up with the same dose that the pharm tech, pharmD, and my unit manager had. I administered the chemo. After the patient had received all of her chemo, she was discharged home. A few weeks later the patient returned to the hospital, received the same chemo regime, discharged home. Repeated a couple of weeks later.

On the patient's third admission for her third round of chemo our oncology coordinator, who was conducting a random chart audit on the patient's chart, discovered that the patient had received an incorrect dose of one of the chemos on each admission. My original dose calculation had been correct. The patient had received half the dose of one of the chemos ordered on three separate occasions. (Twice administered by me!) No less than 6 RNs, 2 pharm techs, and 1 pharmD had calculated, verified, and/or administered the wrong chemo dose. When the doctor was notified she was very unhappy (although very understanding).

I do not know the patient's final outcome. It wasn't long after this happened that I was forced to go on disability. At the time the error was discovered, the patient's Beta-hcg had consistently and dramatically fallen (a strong indicator that the chemo is effectively working). Choricarcinoma has a high cure rate, but I do not know if this patient was cured down the line. She continued receiving the chemo regime (at the correct dose) every four weeks and last I knew her Beta-hcg was continuing to drop. (I highly suspect if her outcome would have been negative, I would have heard further).

I was not fired or turned into the BON. Nor was anyone else. (Obviously there was an incident report, internal review, etc.). I went through a very difficult time. (As did everyone involved.) I second-guessed and questioned myself. Why hadn't I been more insistent and defended my calculation? Why did I allow myself to be "talked into" doubting my initial (and subsequent) calculations? Why didn't I look up the standard dosing of that chemo (then I would have realized the supplied dose was lower than the typical dose)? I even wondered if my declining health contributed to the error. I had been diagnosed with RSD/CRPS months prior and was in an extreme amount of pain (untreated due to the hospital's No Narcotic Policy for employees). I wasn't thinking as clearly as I "should" have been. I felt an extreme amount of guilt and worried greatly about the patient's outcome. It was a very dark time.

That said, I (and the other people involved) received a lot of support. Our unit (doctors, nurses, pharmacy) was a tight-knit group prior to this and we grew closer because of it. We could have easily pointed fingers and blamed one another but that didn't happen. We all felt responsible and for the most part everyone took responsibility for their own part in it. Maybe because so many of us on the unit were involved. Or maybe because we had all worked together very well for a long time prior to this happening. I don't know.

There were positive changes that came about because of this error (some of which our oncology coordinator had tried unsuccessfully to implement prior to this occurrence). One of the big ones was a standardized chemo order sheet used by all of the oncologist. (It eliminated the need for the complicated dose calculation). There were five different oncologists that we worked closely with on a daily basis. They worked closely with the oncology coordinator and the unit manager (and the nurses and pharmacy) to try to ensure that something like this never happened again.

[I love my cat!]

Over the years, I have read many posts on AllNurses (often from experienced Nurses in specialized areas of care) stating that they have NEVER made any errors in their career.

I always cringe when I read those posts.

.....and those posts always bring me back to Nursing School when my Instructor was lecturing and stated: "When you're working and you believe you don't make errors or if you believe you'll never make errors, it is time to take a few months of leave and reevaluate you career as a Nurse. Why? Because possessing that attitude makes a Nurse one of the most dangerous people in healthcare".

I actually don't remember much from Nursing School, but that lecture always stuck with me.

Everyone makes errors. EVERYONE. It's just that some of them actually do get caught.

I'm sorry you're going through this rough time (((hugs)))

[tyvin, BSN, RN]

Oh yes, I love my cat...how so very true! If an RN says she's never made a med error, than there's a concern. The thing is, if an RN really believes they've never been involved in a med error; that's just scary . Believe me, as has been opined earlier; once you've made the mistake the chances of it happening again have gone down 99%. Even so, don't let your guard down; the minute you do it's ooops. I don't mean to be paranoid about the whole thing but that's the balance that we as RNs must maintain. I give an RN 1 year and in that time they should have somehow been involved in something.

I'm talking about RNs who are around meds a good part of the time, like med-surg/LTC/ etc... The desk job RNs who are never around meds can't make med errors if they're never around medications. Of course there are other types of nursing errors. We hold a heavy responsibility.

We don't go into our career with all the coping skills and good judgment that we do eventually develop from the experience we accumulate over the years as we work. It's something that is earned.

You'll be fine