When the boss makes an error

I have seen errors from Drs and nurses. Some times pier (spelling) reports are written and sometimes not, I had a sr nurse tell me once. "if you dont chart it--it never happened"

I had a male nurse on my telemetry floor give the wrong dosage of dilantin then go to lunch. When he came back his patient was dead. Nothing happened to him and he went on to bid into ICU. He is still working in ICU.

Shortly after the incident, this nurse gave an inservice on his mistake. Go figure.

This is interesting...I didn't know that a person would die from receiving the wrong dose of Dilantin. Was it too high? I know that a high dose would cause sedation...can you enlighten me a bit more (so that I don't do the same thing)? Thanks a bunch!

A doctor once wrote an order for clonidine instead of something else and this patient had NO history of hypertension... his BP dropped to 70/30 and needless to say he was transferred to ICU.

A nurse one time gave 100 units of insulin to the patient... she was on orientation.

A nurse gave TPN through a peripheral line and not a Central line and the patients arm was in jeopardy of being lost since the IV infiltrated for 8+ hours.

I think we should be really careful about what mistakes are posted for all to see. Especially details, we never know when a poster is someone looking for an excuse to sue someone. I'm not in any way inferring that the OP is doing this for any other reason than educational, but you never know. We had a pt. recently that had been in MVA, pt and family were looking for anything and actually stated that they would get some money from somewhere, if not from the MVA then the hospital.

No matter how careful we are, mistakes happen. It is up to us as professionals to be accountable for them when they happen. It doesn't mean that we throw ourselves "to the wolves", but going back over the error (or near miss even) and figure out the root cause and how it can be prevented.

I made a big mistake early on in my practice, and luckily, no harm was done to the patient. The root cause was lack of proper training. I was responsible for a procedure that I had a handwritten note from our "staff educator" left for me (I was night shift). She inadvertently skipped a step or two. I fought hard for an inservice for the entire staff, plus voluntary cross training. It never happened. I was labeled a "trouble maker" and eventually wound up switching jobs. I was more than forthcoming about what I should have done - called the unit where they do procedures like the one in question on a daily basis and at least gone over the directions. But I trusted that the author of the instructions was correct.

Unfortunately, my taking professional accountability made someone higher up look bad. Sure it made me a bit mistrusting and angry, but since moving jobs a few times, I've found a place where managment and staff see eye to eye on these matters.

Blee

Years ago I had a HN rip me apart in front of several other staff members for missing an order. The order was not life changing or really too important, but she wanted to make an example of me. About a week later, while working night shift

and doing chart checks, I found a whole page of orders she had missed(she had to fill in that day for a CN who became suddenly and violently ill). These were important orders, so I had no choice but to notify the physician immediately, write her up, and notify risk management. I was off the next day, when I returned to work she attempted to be very nasty to me. I will never forget the look on her face when I told her, in front of staff, she could not expect me to do less than my job in this situation. She had placed the patient at risk for not getting timely care started(oncology orders), and she herself needed to be held as accountable as her staff in these situations. We ended up in the DON's office, but the DON sided with me this time. I quit several months later. I know she was replaced a few months after I left because of staff complaints. One thing I learned from this, I pick up a chart and look back to the previous sheet of orders to make sure nothing was missed. I check and recheck orders before I leave the shift. I initial every order I "take off", and I draw a line under my last order, date, time and sign it as a 8 hr or 12 hr chart check. No matter what the policy of a facility is on chart checks, I have never had one tell me I am wasting time by doing this. The other thing I learned was not to speak to staff in a unprofessional manner in front of others. I am not a perfect nurse but I try to work smart, be professional, and kind. Seems to work in most instances.

During shift report walking rounds, I discovered TPN ordered at 60 cc/hr was running at 600 cc/hr.

I find this thread to be rather interesting...

Many of us are enlightened about the mistakes others make, and are able to learn from them....

The first position I had was at a hospital on the med/surg floor. I had just finished orientation and had my own assignment. It was a hectic night, and I answered a call bell for one of the other nurse's patients. The IV pump was beeping, and I turned the pump OFF without even noting that the IV was infusing a heparin drip.

I was so busy I forgot to tell the nurse I turned off the pump.

A few days later, I was called into the supervisor's office and she told me what I had done. I didn't even realize the magnitude of my error.

It was MY overlook. I didn't even try to place the blame on someone else....I could have argued that the nurse that had that pt should have been periodically checking the IV....then maybe HOURS wouldn't have passed by before the error was noticed. I know I learned a lesson that night, and I thank the Lord the pt was not adversely affected.

Who is your boss? A house sup doing cares? If he/she made a big mistake then incident report and involve risk management. Depending on what the error was, I would call the nurse manager and give her a heads up that the report is coming. Or tell her to come in and handle the situation if that is required. My NM doesn't do patient care anymore so I can't see her making a BIG error involving patients. I suppose you could call risk managment directly if you wanted to side step your boss.

If I felt that my concerns were not being addressed, I would go up the food chain. My NM's boss is the CEO of Nursing. I would write a letter and follow up with an appointment with her.

Reporting your boss to the BON is an option and one that is advocated here alot. I've never done it but it is something to think about if the error is that serious.

Does this info help?

This is interesting...I didn't know that a person would die from receiving the wrong dose of Dilantin. Was it too high? I know that a high dose would cause sedation...can you enlighten me a bit more (so that I don't do the same thing)? Thanks a bunch!

Dilantin has been known to cause fatal arrhythmia's when given IV. It's a drug that should be thoroughly respected.

Not an error by the boss. But once I found a PCA with the wrong settings. And I heard of a nurse giving a patient 10 times the amount of insulin that should have been given. For both, protocol called for 2 RNs to check dosages so obviously that wasn't done.