Well I made a med error yesterday. Not my first one in 17 years of nursing and won't be my last. But this is probably the first one I can remember where the physician thought harm was done to the patient b/c of the error. I screwed up and didn't change times when confirming a med in our computerized system so the time defaulted to 0800, 16 hours after when they wanted the dose given. Well maybe if I hadn't been worried about this patient's airway or keeping the patient comfortable/sedated so he had an airway, maybe I would have caught it. Maybe if I hadn't been so focused on getting the antibiotics into this obviously septic patient I would have caught it. Maybe if this order had been put in a different way I would have caught my mistake. But none of those maybes happened. So the patient didn't get his steriod dose for 16 hours after they wanted it given and per my nurse manager this physician said, "If this patient doesn't turn around we may go to legal services about this."
Okay as if I were not sick enough that it happened when this doctor's nurse came to me in the morning to ask me about what happened I sick now! I made a mistake. I could come up with all number of excuses but ultimately I made a mistake. Human error. I didn't try to hide the mistake. I didn't try to blame the nurse that followed me. I admitted it. I'm human.
But today I realized I, no we as the nurses that care for this doctor's patients, are not allowed to make mistakes. We aren't allowed to be human. We aren't allowed to be anything but perfect. I'm not trying to belittle what happened. I realize the consequence of my action but I can't go back in time and correct it. And this is my patient that I cared for as a baby and would have bent over backwards to do things for him. I wanted him comfortable and to be able to maintain his sats. that is part of why I made a mistake. I was worried about his airway and comfort. Lord forgive me. But also show me the research that 100% says this patient would have turned the corner if he got this med. I don't think it is out there. Never mind this is an immunocompromised patient that has a bad infection and then a wicked virus on top of it. That is not why he is super sick. Would I like to change places with this patient so he didn't have to go through this? In a heartbeat! And the worse part is is that I would not put it past this physician to tell the parents that nursing error caused this patient to get as sick as he is.
Remember....We aren't allowed to be anything but perfect.
Well I'm not.
6 comments:
Lisa..now I understand why you needed to vent.!!! So go for it! I sure understand where you are coming from! Isn't it ridiculous how somehow a person has to take the blame for this when clearly it is a system error?? You may have entered one piece of the order wrong, but where was the pharmacist who was checking the order (JCAHO requirement), and I am guessing you weren't doing a 16 hour shift, so there were other nurses caring for the patient who should have picked it up. This is not a one person problem., so don;t beat yourself up over it!! Been there, done that myself, and refuse to ewear the t-shirt anymore (although it seems to keep appearing on my shelf to remind me!! hehehe)
Wish I had a tee-shirt that says that! too funny!
I feel better today but I've been away from it for a weekend but also had a lot of time to reflect on it. I also got a phone call from the medical director of the unit which was a nice surprise. he is not someone I have worked with for long so it is nice to know i have his support. Until he said "system error" I hadn't really thought about it that way and I'm glad you mentioned it also!
Thanks for listening Bev!
Lisa, you are one of the strongest nurses I know of. You excude care and self confidence. I wish I could send my daughter up to work with you for six months.
We as nurses do expect perfecton out of ourselves. So much of what we do is an art and not an exact science. It's really difficult to realize that eventhough you were doing the very best you have in your whole being you still made a mistake.
Remember the term Sentinal Event? It wasn't a sentinal event! That's what we all live in dread fear of!
Be strong and learn where you gain your strength from. Forgive yourself and move on!
As for the MD who is blaming you for the lack of the positive turning point, it's such a world of CYA and doctor eat nurse!
For me it did come to a point that I couldn't take it anymore. Compliments are few and far between in the world of nursing but a kind word or positive atta girl goes a long way!
I'll never forget when I left my job in the big city one of the Doc's saying, "Well, another good one gone!" For 15 years I worked with this man and when I am leaving, he says a kind word to me.
Vent away! You are a great nurse and you know it deep inside!
Lisa, I'm just catching up on my reading... I hope that the dust has settled and that you're not still beating yourself up over this. Hang in there!!!
Done beating myself up. Thank you all for your kind words! Now I'm mad and ready for whatever he tries next! He tried to be nice, like usual, friendly, meaningless chatter, but I want none of that at this point. Not ready yet!
Tag... you are it! Go read my blog!
Glad you are mad now!
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