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...

[jadelpn, LPN, EMT-B]

Song in my Heart--

You are and will continue to be a mentor of nurses. I know this because you give really good advice on this site. And there are many of us who learn from your experiences.

With that being said, no nurse is perfect. Turn this around as a mentoring experience. If this error occured to a brand new nurse, it could be soul crushing enough that the nurse would not be in a positon to be able to practice well. And you practice well 99% of the time. Like most of us, you are now in the 1%, which is a very small percentage of a whole nurse.

Know that going forward, you are able to make a change in policy that will affect patient care in a good way. Do not be hard on yourself, as we can only move forward from today. Nurses usually do not go into work with the opinion that they are going to cause patient harm. That was not your intent. Just keep swimming.

I want to focus one minute on all of the nurses whose 1% (or perhaps more than that--and if so shame on them) is to tear another nurse to shreds and be caught up in shaming, degrading.....that reflects poorly on the nurses as nurses and nurses as people. And I LOVE a manager who calls them on it--and has education relating to not having this mistake occur again, but also behvior such as this will not be tolerated.

You are the best of the best. Do not let a mistake define you as a whole nurse.

[RNsRWe, ASN, RN]

A couple of others put it more nicely, but I used to have a clinical instructor that would say "any nurse with more than a rookie's experience who tells you she (or he) has not made a med error is either lying or too stupid to know the difference".

I use that myself now, when someone is beating himself to a pulp over an error that anyone could make, at any time, and it isn't the determining factor in whether someone shouldn't be a nurse, or shouldn't be in healthcare.

I also wonder how many physicians have these same wrenching, blood-and-guts twisting moments over giving metoprolol instead of lisinopril? I think nurses tend to expect greater perfection than any human can actually offer.

[RNperdiem, RN]

Physicians do have those gut wrenching moments too, often on a much larger order of magnitude. The more responsibility you have, the greater chance you have to commit a catastrophic error. If you practice long enough, you probably will.

[sweetdreame, BSN, RN]

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.

This is a very "intelligent article". Just because the OP didn't discuss the details of an ongoing situation does not cheapen it. In fact, I think it makes it just a little stronger.

I'm sure I'm not the only one who has ever dismissed a potential learning situation and thought "I would NEVER do THAT!" when we hear of the error made by another nurse. The truth is, OP never thought it would happen to him either. The type of error doesn't matter. That wasn't the point of the article.

I feel like some people want to know what happened so they can lull themselves into the false sense that it could never happen to them. Instead, why not use this cautionary tale to learn, slow down, and be a little more cautious realizing that you are an error-prone human nurse.

[Sugarcoma, RN]

I disagree with the poster who stated we needed details. Details are really irrelevant. This is not a thread about how to prevent an error, it is about recovering from one. I for one appreciate nurses who are willing to come out and say "I made an error." Song in your hearts admission is especially significant as they have a huge presence on this board and if you are familiar with their postings, they are clearly a very knowledgeable nurse. Perhaps this is selfish of me but when a nurse, especially one I admire confides that they too have made an error, even if I do not know the details, it makes me feel better about my own practice. Maybe I am not a giant idiot after all, maybe, instead of blaming myself I should be looking into what factors contributed. Maybe I should stop beating myself up with guilt. Maybe I can drag myself into work for my next shift without feeling like the weakest link. Sharing with one another, honestly, about the difficulties we face in our working environments helps to change the culture of nursing.

If there is one thing I think we can all agree on here it is that the culture of nursing could stand some change. This thread gives me some hope. Multiple nurses from all areas and levels of experience coming together to support a fellow nurse. This is how it should be. What I see in my day to day work environment is not so encouraging. I have to admit that when the OP stated they had received encouragement from their coworkers I was surprised. Isn't that sad? Cynical me was thinking "be careful who you share this with" "watch your back" "this may change". I get so sick of the "out nursing" I see so many nurses participate in. Not one day at work goes by that I do not hear a colleague make some disparaging remark about the person they followed or the person in the next room who did this when what they should have done is this and if it were my patient.......on and on. Enough with tearing each other down. Enough with perpetuating the idea that only the stupid, the lazy, the careless, are involved in errors. The job is hard enough as it is.

[klone, MSN, RN]

Details are only needed for the benefit of the person asking for them. They are in no way needed for us to support the OP. I continue to think about you, Music. Please continue to be strong and be gentle on yourself, my friend.

[SWM2009]

I have to say that this thread is a prime example of why I read and appreciate Allnurses daily.

To the OP, music in my heart, thank you for sharing this. As a long time lurker then poster here on AN, I know you are an asset and a great resource for nurses everywhere. Take care and know you are supported by so many of us here on AN.

Thanks for all the positive comments.

So far, I'm still going to work. Someone told me that there had been much talk about the incident in my off days... Which is precisely why I was open with people at the outset.

I did just receive notice that the incident is being reviewed so we'll see where it goes.

From a cynical perspective, one could say that me being so open about it perhaps reduces the probability of a punitive response only because everyone would know of *why*... Of course, in the ED, if they're going to scrutinize your charting and all, they could generally get rid of anybody if they're really motivated to.

Here's what I keep coming up with...

I am NOT the error... the error is a thing separate from myself.

I am NOT my successes... the times that I've caught a crumping patient, or that I'm the first of the several people simultaneously trying to get access on a critically sick or injured patient, or that in a room full of smart, competent people I've been the one to improvise a desperately needed solution.

Neither am I just the guy who several patients have written glowing comments about... nor am I the mean, insensitive, inattentive jerk that some patients claim.

I am NOT only the nurse who's had several docs say, "I'm glad you're the one working this case" nor am I only the guy who's lost my temper and been needlessly confrontational with the occasional physician.

I am NOT *only* any of those things... I am a whole person, with strengths and weaknesses, who succeeds and fails, who can be cocky as Hades but sometimes humble as (pie?)...

I am far from the best nurse... in my department, in my hospital, on this site... and sometimes not even in my pod or in the room... but neither am I the worst.

I am just a person doing a difficult job to the best of my ability and offering all I have to bring to every situation...

What I did was with the best of intentions to comply with a physician's order to provide very urgent aid to someone who desperately needed it... I was not reckless nor acting with disregard nor malice... and yet... I still made a serious error.

I guess I'd like to think that there is room for me and my tarnished halo.

(FWIW.... the patient ultimately walked out of the hospital...)

I can be a judgmental weenie... I hope this experience helps me to better tolerate those tarnished halos that are around me.

OK... time to shower... hopping back in the ring again today.

[OCNRN63, RN]

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 irony of this post is mind boggling. You complain about your co-workers lacking compassion, yet your post reeks of the very humiliation tactics many nurses experience when a serious error occurs on their watch.

​You (justjude60) reap what you sow.

[OCNRN63, 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...

​Your post just breaks my heart. If I knew who you were I'd send you a card or something...something, to let you know that I support you. I don't work with you, but I still have your back as a fellow nurse.