The weekend that blew up

psalm, RN · Apr 1, 2006

...as far as the allergies, sometimes pts. don't remember all their allergies when they are checked into the ER. When they come up to our floor, I will always ask if they have allergies. Usually I will say something like, I am going to access you and also ask you some questions for our admission. Some will be repeats of what you were asked in ER. I have "caught" allergies that pt. didn't mention in ER and have had to call the Doc b/c he ordered meds pt. was allergic to.

...and before CT and MRI's we have pre-screens that ask about allergies. Sometimes, no matter how often we ask, an allergy will slip thru that the pt. can't remember.

steelydanfan · Apr 1, 2006

My take on the situation:

Error 1: I don't understand all the facts. Your statement that the line was long and entangled does not explain the failure to not check the IV bag.

What did I miss?

Error 2: This happens to many a nurse. We look at the Kardex, or med sheet or whatever, as the standard. NKA means NKA. Right? I had a patient who was allergic to ASA, as stated on her admit form. The admitting nurse transmtted it on the admit pharmacy orders. They saw it, put it in the record, it got printed onto every subsequent MAR.

The MD ordered ASA 5 days into admisssion. I saw it, did'nt remember the allergy (it was in RED on my personal notes), the pharmacy didn't pick it up when transcribing, and consequently, the patient got 2 doses before it was caught by a star RN. Am I a good nurse? Yes. Do I have lapses in attention? Yes. Am I human? Yes.

I felt bad, as did the pharmacy, as did the pt.s doc. Should we all be fired?

You be the judge.

Cate

pricklypear · Apr 1, 2006

newnurse51 - I'm really sorry you had such a bad experience. The two errors you described are so common, I can't believe you were asked to withdraw from patient care. Were you offered any counseling, or suggestions to improve your practice before they gave you that ultimatum?

Anyway, I'm glad you found a job that you are happy in, and I hope all goes well for you. Don't be so hard on yourself. Since you enjoy working with the elderly, why can't you become a CNS in geriatrics, or something related specifically to the elderly?

FLoridarnl · Apr 1, 2006

Wow, I'm sorry this happened. Med errors are very hard to get over. I've made errors in the past, thank goodness no patients were harmed, but EVERY nurse makes errors in his/her career. Nobody who is human is error free.

cygni519 · Apr 1, 2006

First let me send you hugs and prayers......

I am also a new nurse, and made a crazy med error with Morphine a few weeks ago and I posted about it here and received alot of support and great advice. I returned to work and my charge nurses, co-workers and nurse manager all told me that mistakes do happen but that I should focus more on the fact that I caught it and reported it immediately so the patient suffered no harm. That support helped tremendously but it still bothered me of course, but it made me VERY careful. I hate that you didn't have that type of support at your job and had to look for another position, even though it sounds like you enjoy it, please don't let the actions of a few harsh people turn you away from bedside nursing......if that is really what you want to do I hope that you find a position that offers you support and encouragement for you to grow....good luck!!!

newnurse51 · Apr 2, 2006

My error with the IV bolus was that I thought the Normal Saline was on the primary pump. It was hard to tell from the tubing because someone had placed extra long tubing on the IV pump that had become tangled and you could not tell which tubing belonged to the primary pump or which tubing belonged to the secondary pump. I should have painstaking traced the tubing and I didn't. That was my error. I assumed the normal saline I needed was on the primary pump and it turned out to be on the secondary pump. The patient got the solution that was on the primary pump. I was told I had set the pump correctly, my mistake was not realizing the patient was getting a bolus from the wrong fluid.

grentea · Apr 2, 2006

As a new nurse, I made two med errors too. I don't really want to get into what they were, but my patients were ok. I was told that one more, and I'll be asked to leave. I am feeling so ashamed of myself, but I've seen quite a few errors on my floor over the past week much worse and serious than mine (such as piggybacking Dilantin in D5W), but it seems like no one else is being punished in any way. I'm talking to my NM on Monday. I'm sort of thinking about LTC among other things too but I know I'll need to be careful because I've heard stories about crazy nurse/patient ratios at some nursing homes. I think the last straw was the other day when I came in for my shift to find one of my patients with a heart rate in the 130s and her respirations 30-35, and no one had taken her vitals signs for the two shifts before me. Actually, I was the last person to have taken her VS, the night before. I think I might need to start looking again for a new place to work, but it's kind of hard when this is already my second hospital (left the first one because it was pretty much more critical care than I ever wanted). I'm happy you found a good nursing home. I hope I can find a place where I'm happy too!

lberghood · Apr 4, 2006

Errors happen and a most of the time they are part of the "system" and not just an individual error. In the 2 instances that you described you were not the only person at fault. In fact you did not even hang the bag of fluid if i am understanding this correctly and the allergy was missed and not reported to you

I am in no way understating the importance of the responsibility of medication administration and giving nurses "permission" to be lax and not take every precaution to make patient safety a first priority but, that being said. I am shocked that you were asked not to provide direct patient care as a result of this.

You are a new nurse and i can bet that you will never make these errors again and will be extra careful in these 2 areas and these experiences will make you a better nurse because you have lived firsthand through them.

I am curious if the person who hung the wrong solution was also disciplined as harshly. In a perfect world we would have enough seasoned nurses to work with new nurses and help them to transition into their roles but i have seen and heard about countless events where a new nurse with a lack of experience was placed in charge of a floor and lacked the experience with far greater devastating results

So you made mistakes that does not mean that you are incompetent and trust me any nurse who claims that they never made a mistake is not a nurse that i would want taking care of me or my family

Please don't give up on yourself and don't quit your education learn from it and move one. If you need a little time to develop your skills and get comfortable fine but don't let this experience keep you from living up to your potential

I have been a nurse for 17 years and have not taken risks and stayed at jobs that i felt were "safe" because i felt incompetent for a long time. I have just recently realized that i am far from incompetent and am planning to go back to school and took a management position and have found a new found sense of pride and exhilaration with my career.

I also made a pretty serious error in my first year as a nurse. It involved an infant and morphine and thank god the child suffered no lasting ill effects. Also thank god that i was not treated as you were, believe me, i tortured myself enough but i can guarantee that i will never make that mistake again and have become a much better nurse as a result of it. Also the facility I worked with made changes and created a new med room from it which helped to keep the patients safer.

YOU ARE NOT INCVOMPETENT BECAUSE YOU MADE A MISTAKE!!!!!!!!!!!!!!!!!!!

newnurse51 · Apr 4, 2006

I think the hospital acted so harshly toward me because the two errors were back to back. I did not hang the wrong fluid on the IV pump but as far as I know I was blamed completely for the error. This is an error I doubt I will ever repeat. I do realize though that I am glad to be away from hospital nursing. It was too frantic for me - the hospital I worked with believed in a sink or swim situation for all new graduates. Very little support - I worked weekend option so I was basically on my own. One of my first patients I received outside of orientation was MRSA, tube feeder, had a trach that had to be suctioned, incontinent with Stage 3 ulcers. This is the patient they gave a brand new grad. Should have ran then.

MimismomRN · Apr 30, 2006

Newnurse, I just saw your post and had to write you. I too am a new nurse (LVN) and was on my eighth day of preceptorship when they stuck me with a new preceptor, a new nurse also of five months. Well I have always been super careful checking every med five times, oh I work in med surg. Well on Thursday this new nurse had me so stressed out running here and there that when we went to give meds to a G tube patient, she grabbed them and I followed her without grabbing my med sheets or chart and she went to the wrong patient and gave the meds. Then I gave an injection to that patient. I was so stressed out I did not realize we had not checked the armband, etc. When I went back to the chart to sign off, I realized the med sheets had been switched from another chart. I immediately notifed the charge nurse and the doctor was called and we monitored the patient. The patient was okay, thank God. But I on the other hand have been a wreck ever since. Questioning my competence, ability to be a nurse. I can't sleep and don't know if I can go back to work. I trusted her and just followed instead of doing what I knew. My heart goes out to you because I am going through the same thing. I feel like I am having a total breakdown over this mistake and don't know if I will be able to get through it and move on. By the way we have anywhere from 11 to 15 patients at this hospital. I knew this before I took the job, but everyone says you need one year of med surg before they will hire you. I don't know what to do at this point. I am so upset and stressed out.

Trauma Columnist · Apr 30, 2006

I feel so sorry for you! It seems as though hospitals just push folks through orientation! May I ask how long you had for orientation? What kind of floor? I always tell new nurses that I precept that it takes a full year in our ER before you know what questions to ask. However, we would much rather have you ask us then make a mistake. I wish you the best. As to grad school - again don't give up. However, you might want to give yourself a couple of years experience prior to deciding on your specialty. I wish you the best.