Who's fault is it REALLY? aka when my common sense went bye, bye...

[Yenta7]

Has your common sense ever gone out the widow at some point leaving you wondering when the stupid stick hit you afterwards?

During the graveyard shifts, the staff nurses/lpn along with the charge nurse are in charge of doing 24 hr checks on their pts. This ususally involves going through all the pt charts, ensuring all the orders for the day are done and all the labs for the next day are ordered. All the orders for each pt are written in their invidual kardex's. Each Kardex is basically a handy guide utilized by all the charge nurses to keep track of all pt information and their individual orders including things like IV fluids. Usually, the charge nurse will go through each chart on the ward and order any labs for the next day and write down orders into the kardex. The staff rn/lpn in charge of the pt will also do a reconcilliation for their pts-writing down all pt orders and ordering anything the charge nurse misses.

Anyway, I was reconcilling one of my pt's charts. This pt had been admitted during the swing shift. I noticed that in addition to the IV NSS order there was an order that said "IV Heprin per protocol". In my mind all I could think of was "hm, heprin's really important. they couldn't possibly have missed this. The heprin was probably d/c'd at the clinic" So instead of informing the charge nurse, I assumed the order was d/c'd.

In the AM, as I was getting ready to leave. The charge nurse suddenly leaves the report room and says, "---- , there was a heparin order! Did you notice it in your 24hr check?" At first I was confused. I told her, that I had assumed it was d/c'd. Long story short, it wasn't. The nurse in the swing shift had not endorsed to us that the pt was supposed to be on a heprin drip. In fact, the pt drip had never been started! The charge nurse said that she herself had not looked at that chart and therefore did not know about the drip until she was doing report.

Thankfull nothing was wrong with the pt and his cardiac labs had been decreasing since he was admitted and he had been fine. Anyway, after ensuring pt safety and ordering stat pt/inrs and heparin iv, my charge nurse wrote up the incident report. In the report she mentions my name- to what effect I'm not sure-but I think it might have been as a witness.

I know your probably all looking at me like I'm an idiot. Don't worry, I feel like I am. I have NO idea what I was thinking at the time! I've been getting better and reconciling my charts. I'm usually pretty good at catching things that get missed but that night-holy crap I have no idea where my common sense went too. I was really hit hard by the stupid stick I guess. In fact, if anything is d/c'd it would say "d/c so and so" if it had been the heparin it would have specifically said "d/c heparin." I swear I just wasn't thinking about this at the time.

My question is, I know I share the some of the blame for not realizing what I was reading, but who's fault would this actually be? Mine soley? My charge nurse for not reviewing the chart herself? or the charge nurse from the previous shift?

[maryloufu]

Ultimately wouldn't it be the nurse who noted the order?

Don't beat yourself up. We have all been there.

[medsurgrnco, BSN, RN]

IMO there are several people who were responsible for catching this. You said the patient was admitted on swing shift, so the swing shift nurse and whoever else checks orders on admits as well as whoever was responsible for the shift chart check for that shift. Then yourself and the charge nurse on your shift. In my experience, management has been more concerned with the nite shift catching all errors in the last 24 hrs than with each shift catching everything - but I don't think this should be the case, esp. as many nurses do 12 hr checks on their shifts.

[Agnus]

There is a system of multiple checks in place at your facility for the explicit purpose of making sure things like this do not happen. Sometimes even that fails.

It is my estimation that ultimately each nurse involved shares total responsibility. The way I see it one is not more to blame than another and each one carries the full responsibility for having missed this. You each had an obligation to check and note orders and none of you did.

I am not a lawyer but my guess is if this went to court this is how it would be looked at.

I have had moments when I can only say What was I thinking. The brain gets scrambled or something. I sure don't know but I have been there. I know that feeling.

[TazziRN, RN]

The blame does not soley lie with any one person, because at least two people missed it. It was a mistake, no harm was done, and you will learn from it. We have all had those "stupid stick" moments, and this will probably not be your last. This will, however, probably be the last time you repeat this particular mistake!

[PMHNP10]

mistakes do indeed happen, but hopefully this is a reminder that you should not assume because it "make an ass outta u 'n me"

[BlueRidgeHomeRN]

we have all had those "stupid stick" moments, and this will probably not be your last. !

amen!:grpwlcm:

fatigue can contribute to this, as well.:hdvwl:

while working nights, i was severely beaten regularly by the "really stupid" stick:lol_hitti

[imanedrn]

...My question is, I know I share the some of the blame for not realizing what I was reading, but who's fault would this actually be? Mine soley? My charge nurse for not reviewing the chart herself? or the charge nurse from the previous shift?

I may be new, but why is there so much blame in nursing? As long as the patient is safe, an incident report should be sufficient... right?

The fact that you assumed the heparin was d/c'd doesn't make you stupid... it makes you human! Were you super busy? Had you made this assumption based on past similar situations? Were you tired or hungry? Were you making a judgment that you (at the time) believed to be perfectly valid?

As I said, I may be new, but I'm not naive. I realize that healthcare is a whole different playing field than the work I've done before, but (again) your patient was safe. I believe it's more important for you to focus on WHY the error was made and what can be done to prevent similar situations in the future than blaming yourself (or anyone else) for the problem.

As nurses, we may be expected to be perfect (like that damn night charge nurse of mine :argue:), but -- sorry! -- we are human! We will make errors. But we will also make up for them.

Hope all turns out well for you!

[PsychNurseWannaBe, BSN, RN]

Ohh...I hate the stupid stick. I get smacked with that thing more times than I want to admit as a new grad. There are days when I leave work and I feel like a piñata.

Stupid...stupid stick.

[CHATSDALE]

there were multiple checks and this guy fell through the cracks

take this as a learning experience, you know several things the nurse you took report from needs to be double checked

double check yourself, if you find ANYTHING that looks suspicious get some additional information

if you have to call people at home then do it..their sleep would not be interrupted if they had charted and/or followed through with orders

as you go aong you will do things automatically, like riding a bicycle yo will not have to try and keep your balance and pedal at the same time

you don't have to beat up on yourself but you have to self evaluate and you will be a good nurse

[medsurgrnco, BSN, RN]

Can you let us know who management decided was mostly at fault?

[Yenta7]

Thankfully the pt was ok and the md was already made aware. From what I understood from my supervisor, no one nurse is being fingered for the issue. As she said, three other nurses missed the mistake so it can't really be blamed on anyone person.

If there are any other updates, I'll let you know. ^_^