Whose error?

[cenote]

I'm a new grad (May '05) and work at nights in Telemetry. I've been out of orientation for a month now and last night I ANOTHER shift from hell and 2 incident reports. These were both from the same pt who was receiving blood thru a mediport.

First Report: I was called to the room during the admin of a 2nd unit of blood. (About 50 minutes post start of infusion). The 83 yr old, against my specific instructions, had gone to the bathroom without assistance. She said she couldn't wait and wanted me to see what was in the toilet. The bowl water seemed filled with blood. Her dx was rectal bleed but the blood seemed pretty excessive to me ). I called in the Charge who noted the stool and left.

The patient then began to complain about her mediport stinging her. When I examined it, I noted that there was fresh blood on the gauze , and a hematoma forming and so I stopped the blood at the "Y" tubing and opened the saline. I then called the Charge again who sent the assit. charge. She instructed me to stop the transfusion. I turned off the pump. She tried and failed to get a peripheral line and called in the Charge who decided to replace the mediport needle. The Charge was letting me do the replacement since I needed to be checked out on this skill. While trying to access the port and with the pt. complaining of pain and getting very anxious, the assist. charge recommended that we not do this since she said that the hematoma seemed to be getting larger. At this point, I asked whether I should go and call the MD to apprise him of the total situation. The Charge instructed me to do so.

While on the phone with the MD, I told him of the bloody stool, the mediport prob, the prob with getting a peripheral line, the anxiety and pain of the pt. He gave orders: give the existing Xanax order a bit early, a Lortab, and told me he had called for a consult with GI already. He told me he did not know what to do about the mediport but asked if we could continue to try to get a peripheral line. As he was saying this the Charge walked up and said she had gotten an IV in the patients forearm and had restarted the blood. The physician seemed satisfied and all was well.

BUT I had to write up an incident report on the situation.

After the phone conversation I gave the patient her meds. She was exhausted and I knew she needed sleep. Over the next two hours I looked in on her thru the door 2 times and had the aide take her BP. When the time came for the blood to be done, I walked in the instead of the line being red, it was pink. At the Y tubing, THE SALINE HAD NEVER BEEN SWITCHED OVER TO THE BLOOD LINE. I had missed it because the line was still dark red when I walked in to give the meds (from the initial infusion) and in the dark when I checked her, I did not notice it was getting lighter.

The Charge had not switch the lines but had simply restarted the pump.

When I told her about it she said it was my fault and that I should not have turned off the blood and turned on the saline when the first problems started happening with the port. And that she never did that but just stopped the pump. (Actually, I did not recall doing this at the time but know that when there is a problem, and not a reaction problem, that I was taught to switch over to the saline first). I accepted the accusation saying I obviously switched over to the saline and stopped the blood but that she had told me that she restarted it. Regardless, she said she would have to write another incident report and for me to order another unit of PRBC.

Ok . . . Who takes this responsibility? ME? HER? Both?

I know this is long but at this point I'm exhausted and depressed. This was the night from hell with NO pharmacy (on Sat. nights), a very busy Charge Nurse, a new patient (the same one) who could not tell me what meds she had received before admit, and not enough experience and support to do my job correctly. YES, no one was harmed but I feel helpless and hopeless about nursing. This type of problem is ongoing. I'm constantly stressed about pt conditions and not sufficient support. (This night I had other patients who had other problems and was only able to keep them safe, not able to be a good nurse to them). I'm close to resigning . . . and don't know where to turn. HELP me.....God Bless every nurse.

[grinnurse, RN]

I am so sorry that you had a night like this but IMO it looks as if both of you should be filling out the incident report. It was an honest mistake, I believe on both your parts and I would relate to probably the accuity of the patient and patient load in which all nursing/hosp/staff is having to deal with now.

I can't stand it when people won't own up to their mistakes and blame soley another person. The good thing about what happened is that the patient wasn't hurt and you won't make the same kind of mistake again. The bad part is that you have a charge nurse that won't accept her part in the situation which stinks but you will know to double check anything that she tells you she has done and the hospital might have to eat the cost of that bag of blood.

What kind of unit are you on? I know alot of people think things are much easier at night but I would beg to differ b/c of the lack of staffing in the hospital at night. Days to me is much easier even though you have to deal with the Docs and pt families more, at least you have access to usually more people especially pharmacy. Is there any possibility that you could change shifts? On days though, you are still faced with the accuity of the patients and the number of patients that you have to carry. It does suck though that on most days/nights these days that if you keep your patients safe that is a victory in itself. There are rarely days that I can be the kind of nurse that I really wanted to be when I went to NS. All the stuff that we read and learned in school as far as pt care, thereaputic comm., and comfort care other than repositioning and meds tends to go right out the window!!

I would hope that you don't give up on nursing all together but either try to make this hospital work for you or find another hosp/floor or something b/c it sounds like you heart is in the right place and that's important. First thing that you have to do is stop beating yourself up b/c these problems happen to the nurses that have been there a long time. What kind of orientation did you get? You are also newly on your own so that makes a difference in how one percieves things as well. The first couple of months for me on the floor on my own was pure hell, but, I am finally catching on and getting a rhythm going but I wish I had more and better advice to offer. Hopefully, Daytonight will show up. She/he always has good information to share with us newbies.

Best of luck and keep us posted on what happens. Could you talk to your nurse manager about the situation? Good luck.

[cenote]

Dear Grin. . . ,

Thank you for your reply and the pep talk. I'm on a Telemetry unit and chose to work nights since I thought it would give me time to learn before I took on the days. Occasionally though, I do a day shift just to keep my foot in the door, so to speak. During orientation I had 4 different preceptors, sometimes two different ones in the same week. Of course, each had a different methods and modes of getting the job done. Soooo confusing. And it didn't take me long to figure out that most preceptors don't have time to actually teach or answer questions about the disease process. They are there to have you learn the mechanics, the physical skills, the method of delivering care. Frustrating.

I'm not ready to give up yet but I believe that I need to find a teaching hospital in order to get where I want to be and that's going to be difficult where I'm from . . . New Orleans. As it is, I'm in a city where I did not chose to live due to losing my home in Katrina. Unfortunately I was still orienting when the storm hit.

I've been unhappy with my situation and disappointed in nursing since I took this position (I liked my N.O. hospital and training). Having said that, I've decided to resign. I'm desperately trying to find a place to live back near home and when/if I do, I'm out of here. I'm contacting hospitals in N.O. right now who desperately need RNs and will try to get on with one who has a structured Critical Care course so I can transition to ICU. I believe that the lower ratio, and constant surveillance/analysis fits my style. At least I hope so. Right now, I hate that I hate nursing but the fact is, I do. I need to get over it and move on to another experience that gives me some a more nurturing environment...it has to be out there . . . somewhere.

Thanks for your help.

Cenote . . . formerlly of New Orleans.

[Daytonite, BSN, RN]

I'm not so much concerned about the whole situation and who is responsible for what errors as I am that you haven't mentioned what you learned from this whole situation. What have you learned from this whole situation that is going to make you a better nurse? How is it going to change your practice? How can you prevent this from happening with another patient?

[cenote]

Yes, those are very good questions. Looking for the positive is a philosophy I try to adhere to when problems arise.

What did I learn? The major lesson here is that a nurse is responsible for her patients in all circumstance. While a nurse will need assistance in caring for her charges from time to time, especially in the early days of learning, this does not lesson the basic principle that dictates that the "buck stops here" so to speak. I, nor anyone for that matter, cannot not be sure that others will not make mistakes, even those with vastly more experience and knowledge are capable of error. So, always double check any action taken by another when it comes to the care of patients.

How will I keep it from happening again? As I have stated. Rely on myself to check all things concerning the care of my patients.