When the boss makes an error

[proud2b1]

Hey,when your in the field long enough,you will see errors made. I have seen bosses make big errors,have you?Hey,I have made errors, but I have to say they are few and have not been harmful to anyone.It happens. If your boss made a huge biggie would you speak up? I thought this to be very interesting,hope you do to!!!:typing:chair:

[medsurgrnco, BSN, RN]

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.

[maryloufu]

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.

:stone Dang on the TPN.

But I have given that much insulin- felt weird about it, but it was the correct dose.

[BrokenRNheart]

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

"a troublemaker"

I remember some critical chemo treatments we were doing as a research and we had a high turnover on the floor. Charge RN used to set the chemo bags up (total 3 different IV's in a TLCVC) on the scheduled day of admission. One of the tx's was not compatible with the usual IVF and needed another. One of the newer nurses to the floor (1 year exp) with a very apathetic attitude was reporting off to me and said she didn't know what to do but started it. Charge was always available for help and I could never figure out why the new staff would not ask and thought they knew so much. I started to explain the protocol to her which was clearly type written in the orders and easy to read and follow. Standard orders with "fill in dose" lines. She said, "oh well, I hung it with......" and didn't care! She also missed a step (clearly written). Later on this nurse actually chased me down screaming and yelling (over this) and followed me into the pantry like a lunatic. Being newer and cheaper, mgmt (same mgmt that didn't know difference between contin and codone) loved her. I RAN from that unit! I have a lot of stories of errors there and I can't even tell you the service on that floor. Trying to be careful with words here. But it was some critical care on that unit. Also had a newbie blow apart a TLCVC because she clotted it and didn't want to ask for help. I asked for some sort of teaching since it seemed they new staff was intimidated with the protocol. I was treated like I was nuts. I can tell you a lot of patients did not get the protocol correctly - so much for that research.

I don't get it some times.

[imanedrn]

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.

I LOVE the idea of doing your own 8 hr (or any time) chart check! I keep a personal record of the tasks I've completed, but I still have to repeat them back at report / the 12 hr chart check. I think it's a great idea to go back and sign that ***I*** know the previous items have been completed!

[theatredork]

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.

Not to be overly picky, but why not just call him a nurse instead of a 'male nurse'?