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...
I was asked to provide a detailed account to the hospital medication safety committee and have heard nothing more of it since then.
I did hear through the grape vine of at least one person who was spreading the story of my error about the department but it was deflated because I had already shared the truth with many people.
There appears to be no lasting fall-out from the situation though I've not heard anything formal one way or the other.
I certainly have regrouped and become more cautious in my practice.
I have proposed putting together an education module for the docs and the nurses to address what happened but thus far, I've not heard anything about my proposal.
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.
Way to kick someone when they're down
You must have somehow missed that childhood lesson:
"If you don't have anything nice to say, don't say anything at all"
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Thanks for asking.
I am doing well.
I was asked to provide a detailed account to the hospital medication safety committee and have heard nothing more of it since then.
I did hear through the grape vine of at least one person who was spreading the story of my error about the department but it was deflated because I had already shared the truth with many people.
There appears to be no lasting fall-out from the situation though I've not heard anything formal one way or the other.
I certainly have regrouped and become more cautious in my practice.
I have proposed putting together an education module for the docs and the nurses to address what happened but thus far, I've not heard anything about my proposal.
It is exhausting in an ED environment....been there done that. ((HUGS))
Specializes in Critical Care; Cardiac; Professional Development.
I am not sure why I am just reading this. I make a point of reading your posts all the time. I find this like a weight in my gut. I am approaching the three year mark and there are days (many lately) where I leave work almost euphoric over my budding ability to handle the chaos of my job. Things that used to throw me completely no longer do and difficult assignments rarely pan out to be as difficult as I anticipated simply due to my increased ability to multitask and manage my time. I am good now at diffusing situations, I have had a few really great catches on things the MDs or ER missed when a patient came in. It has been great being me lately. I am becoming the nurse I always wanted to be.
Your post has been a sharp yank on my leash. Your words of "slow down, slow down, slow down" echo in my head and I suspect will for a long time to come. My stomach is knotted up almost as if your error was my own. I can so easily see something happening right now. Perhaps my ego has gotten a bit cocky, I have gotten a bit too confident, I am feeling a bit too flush with knowledge. My mind drifts to two days ago when I received a verbal order for 5 mg of Haldol and when I put it into the order set I was prompted for 2 mg. I simply changed it to 5 mg. A niggling voice very briefly wondered about it and I just kept on moving because the patient was agitated and a danger to himself and becoming increasingly difficult to care for. I should have paused. I should have looked it up. It doesn't matter whether that dose is in actuality very safe, what matters is that I didn't actually know for sure, some piece of me recognized I didn't know for sure and instead of taking a moment to check I trusted the doc and kept on moving. Stupidity. How close am I to something serious? Pretty close I would wager. My gut is telling me so. You have yanked me back. Thank you.
I am glad you are doing well. I am grateful you shared your story.
So glad to hear you are doing well. When the incident I was involved in happened, it took a long time for me to come to terms with it. It was such a complex situation with so many others involved (6 other RNs including the unit manager, 1 pharmD, 2 pharm techs) but I blame myself. I didn't trust my gut and someone else--someone who put their trust in me--paid for it. Still brings tears to my eyes and a deep burning in the pit of my stomach even now 7 years later. Every time I gave chemo after that or even verified chemo for another RN, I thought about it.
I really admire and respect the way you have handled yourself. I would encourage you to appeal to the powers that be in regards to your proposed educational module. Positive changes can come from medical errors. In our case, our oncology coordinator really took the lead and we came together as a unit (with input from the oncologists, pharmacists, pharm techs, and nurses) and made some really positive changes. There was not an attitude of blame but rather an atmosphere of "how can we make sure this never happens again". We were a tight knit bunch before this happened and even more so afterwards.
I was a really good nurse before this happened but I will admit I had a bit of a cocky attitude thinking I was above making a serious error. I didn't think I would ever be one of "those nurses"...until I was. It really only takes a single second, a momentary lapse in judgement, a little tiny doubt in that gut instinct. But if I was a really good nurse before the incident, I was an even better nurse afterwards. Music in My Heart, I suspect you are too!
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
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'm not even sure what to say about this post except that it's horribly ignorant. Nurses are compassionate people, for the most part, and I seriously doubt that any of what you've written applies to the OP. It may, however, apply to you.
traumaRUs, MSN, APRN
87 Articles; 21,287 Posts
Music - you are such a class act! Best wishes with the resolution of this issue.