Friday, February 09, 2007

Mistakes

Let's start here: I've never killed anybody. Yes! Score one for the big guy. To the best of my knowledge I've never caused serious harm either. Here are some of the mistakes I've managed to make in the course of my career so far:
  • Informed a patient's parents that we would call them when their child was off the heart bypass machine and back in the intensive care unit. That went down like a lead balloon as the child was in fact having spinal surgery. Oops.

  • Gave a medication IV when it had been switched to oral.

  • Gave a larger than usual initial dose of adenosine due to making an assumption about its concentration which turned out to be incorrect.

  • Gave a medication that recently passed its expiry date.

  • Missed giving a charted medication due to rushing and not checking the chart carefully enough.

The reason I know I made those mistakes is that, where I didn't discover the problem myself, I was notified by the constant checking and cross-checking and reviewing of my colleagues. It's a given that humans are fallible, and that in an increasingly complex hospital world, we will screw up from time to time. The trick is to minimise how often that happens, not to make the really big mistakes, and to put measures into place that reduce the risk of them happening again.

I've caught any number of mistakes from both nurses and doctors. Some examples follow. In each case I can see exactly how the mistake was made, and I can imagine doing that myself given similar circumstances.
  • A ventilator's pressure release valve screwed in all the way, which would not allow excessive pressure to be vented to atmosphere.

  • A bag of IV fluids made up correctly for the unit's standard orders, but incorrectly for the particular patient who had other requirements.

  • A 'ten times the dose' charting error made by a tired registrar.

  • A ventilator set up 'backwards', with the expiratory limb plugged into the inspiratory flow outlet. Patient was ventilating fine but it confused the hell out of the humidifier.

  • An unnecessary medication prescribed by a consultant who made an assumption about the patient that turned out to be incorrect, based on a mis-reading of a fluid balance chart.

  • A dopamine infusion advertised as 5 mcg/kg/min by an anaesthetist that was in fact 10 mcg/kg/min. Sort of explained the extremely 'healthy' blood pressure we were getting.
I mention these not to try to sound clever, but to illustrate that the process works both ways. You make some mistakes, you catch some mistakes. There's a peculiar kind of ego-supression that has to go on in order to survive in this environment, where you swallow your pride and realise that you're not super-nurse or super-doc but rather a mere fallible mortal who gets it wrong some of the time.

I know that people who come into hospital would much rather believe that mistakes don't happen, but the truth is that little mistakes happen all the time. Big mistakes, thank god, are much rarer and (if you're careful, and lucky) tend to be the sort of thing you hear about but don't see.

The same themes recur throughout incident reports submitted when a mistake is made: haste. Overwork. Overtiredness. Inexperience. The risks inherent in understaffing are well documented. A less popular admission among hospital staff is that, even under the best circumstances, errors will still occur.
Posted by PaedsRN at 8:54 AM
20 Comments:

Anonymous Attempting to be Humble and Gracious, at 3:18 PM  

Excellent post. Being humble and gracious helps in preventing mistakes I find. I made a mistake in transcribing a Vanco dose. The nurse I worked with tore me to shreds (followed by hours of silent treatment). It acutally did no harm and the Vanco levels are theraputic (not an excuse). The next day the same nurse was found to make a similar mistake. She was so 'horrified' at my mistake that she didn't pay attention and made one of her own.

Anonymous S. R., at 11:00 AM  

It happens. No need to tear someone to shreds. I'm sure that nurse has either made mistakes based on inexperience or sometime in a very long career. Just as long as you arent chopping off the wrong foot.

Anonymous Anonymous, at 8:03 PM  

Hrm. Well, I was going to post again today but Google in its wisdom has forced me to convert my old Blogger account, and now Mediblogopathy won't let me post. So until we convert to new Blogger I'm confined to the comment space!

Blogger PaedsRN, at 8:04 PM  

NOT anonymous! Not not not! Grrr.

Blogger Nurse Practitioners Save Lives, at 3:55 PM  

I almost gave the wrong patient the wrong medication because I was rushing. Thank goodness I caught it beforehand. It scared the crap out of me and I've been EXTRA EXTRA careful again almost to the point of obsession.

Blogger genderist, at 7:35 PM  

I'm really nervous that one of my coworkers is on the road to making a huge mistake because she gets rushed and flustered. I've talked about her about this and to my coworkers about this, but everybody shrugs their shoulders in her "years of service" and looks the other way.

I'm usually a dealer in tact and kindness, but how do you tactfully tell someone that they're not cutting it anymore?

Blogger shrimplate, at 9:24 AM  

Everybody makes mistakes. Under pressure-cooker staffing conditions which are now rather the norm, this can be expected.

What amazes me is the relatively tiny number of nursing errors made, and how inconsequential these tend to be.

A late med. A missed lab draw. An unsecured oxygen tank flying into an MRI machine.

OK, so that would be bad.

But I think you all get my meaning. Nursing mistakes, as opposed to mistakes made in the general population, tend to be rather benign because we have a strong system of checks and balences.

Sadly I must admit that this nursing culture of intolerance for mistakes sometimes affects my personal life.

Last weekend when we went to the movies my spouse, who was responsible for the parking receipt, lost it and instead of comped parking we had to pay $12 and we had *no* cash, being debit-card folks, and the parking guy couldn't process debits. So my spouse had to write out a check while cars were honking at us to hurry up.

I found this to be distressing and later had to apologize for being impatient myself.

Such is medical culture. Mistakes are not to be accepted. But these are inevitable.

Anonymous jj, at 2:45 PM  

In 30 years of nursing I have made many mistakes that were caught by me and only 1 that was noticed by someone else. I have found that saying the words "I made a mistake" are powerful and usually ward off other nurses attacks.

Blogger running wildly, at 10:00 PM  

As a 3rd year student nurse I have heard horror story upon horror story from my instructors. They ingrain in us to check and check and then check again. "IF YOU MAKE THE MISTAKE, YOU ARE ULTIMATELY RESPONSIBLE." It's a terrifying reality, but none the less a reality. Not everyone makes a huge mistake, not everyone kills someone. It's nice to see that is also a reality, not some far off dream. I think the other commentors are very correct in saying that if people are rushed or flustered mistakes are easily made. So the question remains, in the heat of the moment, how does one not allow themselves to get that flustered? It must be an art.

Blogger ERRN, at 10:53 AM  

Thanks for this post and these comments...It is scary when a mistake is made even if it non life-threatening. Learning to keep your head up in a non-forgiving milieu is even more difficult.

Anonymous Arrowwind, at 2:01 PM  

I'm a nurse. Been at it for 26 years. I know exactly what errors are made and when at work I ususally know by who. I have seen errors kill patients on several occassions. So consider yourself lucky. You haven't done anyone in.

Last year my husband went to the hospital for a choli. Aside from the possible blunders in surgery that I can not be sure of, he ended up with a Rou-n-y, that is his liver attached to his intestine because the bile duct got cut the care was not too great.

What I did directly see was that after leaving recovery and being sent to the floor the RN was satisfied not to check his pca morphine pump. I insisted that she check it. Sure enough, he was being overdosed. Twice the dosage the doc ordered. So two nurses at issue here. Whoever put the pump on and this nurse who would not have checked it unless I demanded so.

The next day I arrive at 9am. There hanging on the IV pole is a bag of antibiotic, full, and the pump not turned on. I called the nurse who had been on duty since 7am. She quickly started the med. The med was now 5 hours late, a med due to be given 3 times a day. Again, two nurses at fault here, the nurse who hung the bag at 4am and this nurse who didn't bother to look the patient over, his lines and what was hanging on the pole.

Then my husband comes home on Wednesday. By Friday eve I see redness growing around his incision. I was worried. No problem though, he says. He went in to see the surgeon today and he said to just keep an eye on it. So we did. Saturday I watched the redness grow. I called his surgeon. No return call. That evening I called his other surgeon and he was started on antibiotics right away.

What was his first surgeon thinking? Waiting for the incision to dehisce? Redness, heat, inceased pain were a sign of infection in a surgical wound, or so I thought.

BTW, this all occurred at Cottonwood Hospital in Salt Lake City. Are the other area hospitals any better? I doubt it.

Visit my blog for alternative healthcare views at
www.HealthSalon.org

Anonymous Anonymous, at 10:14 AM  

Sorry, but were 0-2 in my family for horrendous medical mistakes. Mine was a doctor(a quack or nut-case)really, who tried to get my spinal fluid about 7 times, much blood & pain included. He didn't know how to perform this procedure, & not to go into detail, but my life has been a living hell since. That happened about 8 years back.
I now have a condition called Arachnoiditis. Never heard of it, do some research, & you will do humanity a favor. I suspect that's my diagnoses(self-diagnosed)because the mistake was covered up by all hospitals involved.The second mistake was the same hospital system about three years later. My elderly mother walked in to the emergency room...(these mistakes were all emergency room doctors) because she had a discomfort in her chest, kinda like a vitamin got caught she thought. Well again long story short, the quack in charge tried to thread a catheter up into the heart, but punctured the femoral artery badly...she nearly died right there, lost SIX pints of blood on the table, with numerous transfusions necessary. The blood that leaked into her body cavities caused her spleen to rupture, upon which she then had to have surgery. The spleen was causing sepsis high fever, etc, some young hot-snot nosed doc said I can get it all through a small hole endoscopic surgery. But my mother, who thankfully was a former nurse was too smart for him, she pretty much said my a@@ you can...left the hospital & went to another one, where emergency surgery was scheduled for the next day by a much older (highly experienced)& caring doctor. Next day after about 4 hours of total open abdominal surgery, he came walking covered in sweat into the waiting room with a smile on his face, he must have been about 70 years old...He said, well I think I got ALL the infection out, and you know what, he had. My mother is still alive today because there are some doctors who actually take seriously their patients health. You young hotshot doctors would take a lesson or maybe go back through an experienced medical college, where the first oath you take is FIRST DO NO HARM!!! a big Thank You to all the caring nurses & doctors who actually studied & admit if they don't know a procedure well enough to do it instead of ruining peoples lives. Thank you...........(posted 3-24-2007)

Anonymous beajerry, at 8:40 AM  

Nice catches and good post!

Anonymous Nav, at 6:55 PM  

I am thrilled to find this site! I'm a 3rd yr student nurse in Montreal and am about to start an externship at a large downtown hospital. You blogs were super helpful...thanks!

Blogger whoops, at 2:38 PM  

I was overtired and accidently cut the knots off of some sutures I was trying to remove, making them impossible to remove at the time. An hour later they had all worked out a bit and were removed by another nurse. I was told I could lose my job over it.

Blogger Crystal, at 8:22 AM  

I recieved report on a pt with a Diluadid PCA and I went thru my shift and switched out the syringe once and was going to do it again before I noticed that the basal rate was set at the hourly limit. OMG. i couldnt believe it. I actually looked at the setting when i changed it the 1st time, it just didnt sink in that the hourly limit was set as the basal rate. it scared the crap out of me too. Now I read it twice and say it out loud.

Blogger buzzbees3, at 9:08 AM  

I have been a Nurse for 18 yrs and quite sure have made some mistakes but Thank God nothing fatal. I do know that being helpful to others instead of yelling can help much more. Everyone has tough days I mean peoples lives are in your hands literally after the MD pops in for a few minutes. Arrowwind, Unfortunately I can believe the mistakes made over and over in your husbands surgery. My husb had a knee replaced, when they sent him to med-surg, the nurse came in and asked if he wanted a(1) vicoden. He was in great deal of pain so I asked to see his chart. He had orders for IV morphine, 15mg oxycodone as a next step and then when pain getting better 1 to 2 vicoden. I had to argue with every shift, new nurses and it was completely ridiculous. They had his leg in a CPM (sometimes incorrectly) quite a bit of the time. He was up and moving the first night but only because he had some pain relief. Some nurses need to have a little more compassion. I also found an IV bag of antibiotics still full from his 8am dose at 1pm.

Blogger john, at 7:10 AM  

i have been in nursing for 32 years, sure i made a fare share of mistakes and luckily no one got kill. we all make mistakes, hopefully we are learn from it and become a better one. Thanks for your posting.

Blogger Carla, at 5:33 PM  

I of course have made mistakes. I beat myself up everytime. None fatal. THANK GOD!!! I learn something NEW everyday. I love my job. (peds nurse)

Blogger Gail, at 3:29 PM  

Whoops, Yes possible to lose your job and possibly your license over this. I lost my job on account of the same thing. My license was under review, and fortunatly I did not lose them but I have to now show every person that hires me the letter from the nursing board to let them know what I did.

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