The Med Error

My first med error (and as things go in ones career, the one I VIVIDLY recall the most) happened when I was orienting on days, my first job as a brand spanking new RN on an extremely busy ortho-neuro-gyne-med-surg floor (years later, my co-workers and I took to calling our unit 'The Dump'. Anyway...)

I had an absolute KICK-ASS preceptor who'd been working there for decades. She was smart, talented, hard-working, dedicated and blessed with a dry sense of humor She rode my ass mercilessly all shift long, every single day at work. Her simple rationale: "I'm not trying to be a 'nag' but I'm trying to give you an idea of how really hard this job is. Make use of me, my time and expertise the best you can NOW... because in 6 weeks or less; you'll be ON YOUR OWN".

She scared me poop-less.... but she also made me sit up and take notes.

Now, all "background story" aside:
I was on my last shift of week 3 of orientation. I had a 79 year old post-op ORIF of the Left ankle. I'd gotten through the initial 4-hour period window of post-op patients with their constant monitoring... heck, I'd even gotten 70% of my documentation done. I grinned to my cocky self and thought 'this is going good'.

As are many patients who are post surgery, pt. developed nausea and vomiting. There was a standing order for Droperidol (Inapsine). I drew up the right amount, checked it against the MAR, and showed it all to my preceptor before walking into the pts. room to administer it.

I administered the dose with no hassle, flushed the port and after reassuring the family that the medication should help, left the room to chart.

15 minutes later, as I'm walking by the pts. room, I notice that she seemed drowsy. "Maybe pt. is just tired." I told myself; "After all, pt. has had a long day." I congratulated myself on the quick intervention to resolve pts. nausea/vomiting and my head ballooned with grandiose ideas of what a 'kick ass nurse' I was going to be.

Well, as they say - pride commeth before a fall.

Half an hour later, as I was walking by rounding on my patients, I noticed that the pt. I'd administered Droperidol to seemed to be in a REALLY DEEP SLEEP.

My "still-cocky brain" somehow managed to tarry a tad bit longer to ogle its fine work. Ahhh, she's resting so comfortably....
That was when the "other" brain's screams became more audible.... "she's not breathing! She's not breathing! She's not bre...." (and so on)

!! PANIC !!

Klaxons went off in my "cocky brain" and my bladder did it's best to burst past my sphincter and empty itself in a glorious waterfall onto my shiny new white scrub pants...

I somehow managed to "rush into the room" while also not outwardly appearing to "rush into the room". My mind was racing the speed of light and winning, while all my lungs could do was echo the "Oh my god! Oh my God! Oh my God" chorus... as my heart proceeded to jump out of my mouth and take off for parts unknown.

Outwardly, while I did my best to not appear to be the nervous debris that I was, I attempted a feeble smile at the family as I managed to croak "I'm just here to make sure XYZ is all right"... while my stomach was doing somersaults worthy of an Olympic gymnast medal.

The pt. was a 'little hard' to arouse. But to a noobie nurse like me, anything less that "full arousal" was = "comatose". Even though my heart was incognito, I could feel its rate climb into the Ionosphere. A cold, icy ball materialized in what was left of my stomach....

"Cocky-brain" had been replaced by "Panic-brain". "I killed the patient" seemed to be the medley of the moment - interspersed with "you are an idiot" and "how stupid of you" and various other choice epithets [I'm omitting a few phrases (ok, LOTS of phrases)]....

Miraculously, from somewhere in the depths of my foggy (non panic-ky) brain, I latched onto an idea. I walked outside and brought back a portable pulse-ox machine. This way I'd have an idea of the pts. heart rate and oxygenation while I manually counted the respiratory rate and the blood pressure.

My initial readings were fairly "normal" (i.e. not too deviant from pts. known baseline and previous vitals)... save for the respiratory rate. For the rest of the shift, it hovered around the 12-14 mark (while the other signs stayed stable).

For the remainder of my shift (6 hours), I was in that room as often as I could (sometimes as often as every 5-10 minutes).

Throughout all this drama, my preceptor kept mum - except to encourage me to check in on that patient as often as I could while also hounding me about my other patients.

By the end of that shift, I was a wreck. I was convinced I'd nearly killed the patient. I had worse than a "lowlife no good slacker" opinion of myself. My report off to the night shift was very somber and gloomy.

As I plopped my weary butt down to chart after the shift, my preceptor mosied over and nonchalantly said "you want to talk about it?"
Dejected, head downcast, I mumbled "I'm so sorry. I don't know what happened. One minute pt. was fine but the next minute.... well; I don't know what to say!"
She simply asked "Well, what do you think happened? What do you think caused the pt. to become that way?"
"I really don't know", I stammered. "I wish I did!"; I said, somewhat emotionally.

"Walk me through it. Walk me through your interactions with that patient during the shift".
And so I proceeded to describe it all, in painstaking detail.

"Do you think any of the medications you gave the patient over the shift might have caused that?"

*Blink* *Blink* "Why, now that you mention it, the whole damned business started after I medicated the pt. for nausea!"
"Well, what did you give?"
"Inaps.... wait a minute!"
"How fast did you give the Inapsine? Did you give it slowly over a good 1-2 minutes?"

I thought real hard. And then it hit me - in my eagerness to relieve my pt. of nausea/vomiting; I might have slammed the medication in too fast. 0.625 mg didn't seem like "a lot" to my dumb-brain... but I'd forgotten to take other criteria into consideration. Not to mention the cardinal sin of administering a medication I wasn't too familiar with - especially with regards to effects AND side-effects.

My face turned a beet red: "I... uh... might have... ummm ... given it a little too fast".

My preceptor smiled and winked at me and said: "Lesson learned".
I was thunder struck!! "WAIT!", I sputtered; "you KNEW all along??!! WHY didn't you tell me???!!!"

"Because I'm here to teach you and you're here to learn. Knowing you, I'm rather confident that after today - you will never give any medication without knowing what it can and cannot do... and how to give it appropriately. Being a nurse is more than charting meds and giving them as ordered - as you've no doubt learned today."

She then reached over and patted my back and said: "Don't beat yourself too much over it. I was observing the patient all along too. Your subsequent reaction to the patient's status is commendable - if a little inefficient. But, you're learning and you attempted to do the right thing; which is what counts any way. Someday, I'll share my own 'learning lessons' with you. But for now, finish your charting and I'll see you tomorrow".


It has a mark left in the only place that counts. No matter how old or how experienced you get...
You never forget it.

The Vent

Quoting another ED nurse:

Ok,..was gonna try to stay out of this,.but I just can't help myself! I agree that this is a great place to vent. This is supposed to be a safe place to vent. A place to let out all my frustrations away from patients and co workers. A place to verbalize all those thoughts that I would NEVER, EVER say to someones face while at work! A place to voice my opinions to other health professionals who understand where I'm coming from.

I don't expect solutions to my frustrations. I don't expect someone to tell me how to fix everything and make my job a day at the park. It just makes me feel better to write it all down and get it out! It makes me feel better for someone who understands to say "yeah, I'm with you there!". If occasionally I learn something in the process of venting then good for me! If commenting to someone else's vent makes them chuckle or breathe a little easier that's great.

I've been a nurse for a long time and I do understand that those who aren't in the medical field don't always understand what I'm venting about. I've often whined about something to my husband (a non medical person) that seemed like an obvious situation to whine about and he looks at me like I'm crazy! I then have to go into more detail about my complaint and sometimes he will understand.

That's why I come here! I shouldn't have to explain to any of my fellow nurses how it makes me feel when a 22yr old tells me he has abd pain 14/10, can't keep anything down, while eating Cheeto's and coke, talking on his cell phone! There is no need to explain my initial thoughts when he then tells me he has no medical hx, takes no reg meds and is allergic to Tylenol, toradol, haldol, vistaril, naprosyn, ultram, and phenergan!

I come to this site because we are all in the same boat. We are all caring, compassionate, well educated, professionals who are trying to do the best we can for our pts. We get frustrated when, because of situations beyond our control, we can't do our jobs!

I would never, ever, tell a new Mom, who is worried about her 8mo olds 2hr temp of 102 that she is wasting my time and resources by coming to the ER instead of running to walmart to buy some tylenol! I would never, ever tell the man with back pain for "about 2yrs now, no one can figure out what's causing it" that he needs to loose 100lbs and find a family doc to take care of these "flair ups".

BUT,.when that same Mom comes up to the triage desk and complains that they have been waiting "almost an hour" and "people who came in after us have already gone back" and then gets nasty with me when I explain that the sickest pts go first, I'm gonna come to allnurses and VENT! I would so love to take that Mom by the hand, take her back to Rm 3 the 6yr old who was found in the bottom of the pool, then to Rm 5 the 18yr old unrestrained driver of a roll over MVI who was ejected, then to Rm 8 the 60yr old who suddenly couldn't speak and has a L sided facial droop, Rm 24 the 22yr old ruptured ectopic with a BP of 54/20 who is bleeding out faster than we can put it in and of course OR is full! I would so love to put everything in perspective for that Mom,..but alas,..I can't,..I won't.

I come to this site to vent to other nurses! To those that know exactly what I'm feeling. I don't vent to my neighbor or my hairdresser. I'm not directing my vent to any patient or family member. I'm here to talk to other like minded professionals!

If you have stumbled in to this site as a non medical person, just looking for an interesting read, or free medical advice you should be prepared for what you might see. Nursing can be a very unpleasant job at times. We see people at their worst. We see things on a regular bases that most people will never witness in their lives. We are expected to leave the room of a dead 3yr old and smile and ask Mrs Jones if "there's anything we can do for her, I have the time".

We are expected to understand that when the doc orders 100 of Morphine, he really meant Fentanyl. We understand why our pt with SOB really does need an 18g in the AC. We understand why a pt with abd pain must stay NPO. We know how to do our jobs and we do understand that non medical people don't understand!!

I find it insulting for a non medical person to make judgments on how I do a job that they couldn't do. I don't argue with my mechanic about the best way to fix my car. I don't argue with the electrician about how to fix my furnace. WHY WHY do people think it's ok to not only argue with us, but accuse us of being cold, and uncaring when we are doing a job that many people say they could never do?

I must stop,..if you are a non medical person and are offended by what is said on this nursing site,...it's simple,...see that little red box with the white X in the top right corner of the screen? Click it!

You ROCK lady!

Why I do what I do...

A very thought provoking entry on Float Pool RN's blog prompted me to post the following.

It isn't exactly something new.... but it does give a glimpse into my past.... and possibly my future.

A glimpse of why I do what I do...

I was a student nurse.

Working our first peds rotation at Children's Hospital. This rotation was always high in demand - I picked it for no other reason because I wanted to figure what peds would be like [and definitely for the instructor. I loved her to pieces - she was just completely awesome! :-)]

Up until that time - I really didn't have an idea of what I wanted to do once I got done with school, yeah? I had some vague ideas of getting into some kind of critical care at some point in time.

Anyways, this was my last week of clinicals. Up until that point, the whole experience had been a roller coaster. We had some really sick kids who coded and didn't make it and also some sick kids who got well and went home. Peds was starting to "affect me".

But my last patient was the cake.

She was in for a double ureter re-implant. I was assigned to her the day after she'd had the surgery. She was this really sweet 6 year old girl.

Absolutely the bravest person I've met in ages.

Ne'er a cry or whimper. She was absolutely delightful - never asked for pain meds unless it really really really hurt. Despite my assurances that it was ok to ask for something to make the pain go away - she never did.

We were assigned 8 hour shifts and I went about it my own way - general checks/assessments q2h, checking her tubes (2 JPs and 1 SP) and drains Qh. Meds as ordered. Gave her baths. Linen change. Played "chance" and some other games - heck, even played with her stuffed toys! LOL

The only thing she wanted to know was when could she get outta bed - because she wanted to go for a ride in the toy cart :-)! She asked me all kinds of questions, from her body, her condition, to me, my background etc.

So anyways, I go back the next day. And I'm assigned to her again (mildly surprising. I'm the only guy in our batch on the floor who has constantly been reassigned to the same patients. I didn't find out till the end of our rotation that this was done at patients request - they'd liked me and the job I did so they wanted me again!)

So I walk into the room to do morning assessments and while checking her BP I could see she was trying hard not to giggle. So I turn my back to get her meds - and I can see her squirming in her bed. So I ask her what's up.

She asks me to close my eyes, she has a surprise for me.

I close my eyes and in my hands, she places this little card. Made in green paper.

It said "To Spook

Thank you for taking good care of me

from,
XXXX"

Her Mom explained that she'd spent 4 hours, painstakingly drawing with her right hand (she's a southpaw but her left hand was boarded with an IV board).

My vision was blurry. I don't cry easy but I did feel that one tear drop down my cheek. I gave the kid a warm, heartfelt hug.

I'd been having a horrible week to the point that I even came to doubt myself. I was wondering if I'd bitten off more than I could chew. Debt was killing me. Working two jobs just to barely keep my head above the water, sleeping about 4 hours a night at best etc. etc.

That card and her smile when she gave it to me changed all that.

That was when I decided - right then and there - that it was all worth it. That's when I decided that when I graduated, I was going to do peds. Life or death, sickness, suffering or recovery; I just knew right then that I'd be doing it with kids.


I'm still workin' on that goal...

Professional Nurse? Or "trained monkey" ?

My appy-pologies to MonkeyGirl. I simply use her moniker because it is an apt 'term' pertaining to the situation.

New rules at my hospital following JCAHO recommendations: If a PRN medication is ordered in a specified range (dosage or strength), it is not ok to administer a dosage less than what has been ordered.

For example: I have an order for: Morphine 3-5 mg IV every 2-3 hours for pain.

Now not only am I not allowed to exercise critical thinking and nursing judgment by figuring out how much medication my patient needs, I am also supposed to automatically interpret that medication order to read: "Morphine 3-5 mg IV every 2 hours for pain".

"So what, Spook?" you say. "It follows The Joint Commission (cue reverential music) recommendations on the very subject. In fact that med order that you gave as an example is cited by The Joint Commission (cue reverential music) as something to be avoided - you can see their recommendations here. Your organization is just following recommended policy".


So, if someone is ordered 6 mg Morphine IM for pain, I can't exercise my critical thinking skills and administer 4 mg because the patient may not need 6 mg (or maybe because 6 mg would be an unsafe dose. More on this later). Instead, I'm supposed to call the physician and request s/he lower the dose.

All medications carry side effects - why administer more than that which is required? Don't get me wrong, I don't think patients should sit around suffering in pain (not only is it inhumane, but constant pain slows down the recovery process). But to dose them 6 mg when 4 mg work just fine is just plain stupid.

"But Spook, you can always call the physician and have the dose lowered. Aren't you bothered with medication safety?"

Well, yes, I could call the physician. And it works fine for a couple hours. What if the patient starts reporting increased pain? Now I have to call again to get the dose increased! This seems fine and dandy on paper - but it's a fools errand in real life. I am yet to find a nurse in the trenches who agrees with this approach and implementation.

"But Spook, that's why they have dosing ranges".

Right and wrong. Dosing ranges exist - but no longer do we have (say for example) 'Morphine 4-8 mg IV'. Ranges are now supposed to be much narrower along the lines of 'Morphine 4-5 mg' or some such. I welcome folks to handle a single post-op patient on my floor with such narrow dosage strengths...

Remember earlier on in this post where I mentioned the fact that a patient may not need the dosage ordered? I once had an anesthesiologist order "6 mg Dilaudid IV push now and repeat in 10 minutes" .... for an 86 year old female with a hip replacement with a respiratory rate of 16. I repeated the order four times to clarify - and each time he was adamant it was right.

Needless to say, I didn't carry out the order. I exercised clinical judgment and gave the patient a bolus of Dilaudid 0.5 mg and it helped her immensely. Patient reported good pain relief and was resting comfortably within 30 minutes. I documented the hell out of that incident and also placed and incident report - and made sure the floor Director knew what happened.

Now technically, according to JCAHO - I'm not supposed to do that. I'm not supposed to administer less than the dosage ordered. While it's easily obvious in this situation as to why I shouldn't have followed recommendations; I use this example just to point out that a lot of times, it is not as clear cut in black or white. Precisely why Nurses are taught critical thinking and are allowed to exercise clinical judgment.

Ladies and Gents, unless I'm missing the big picture somewhere - all this new intrusion by The Joint Commission (cue reverential music) is simply eroding my authority as a trained medical professional. If I can't be trusted to exercise my judgment in determining the appropriate intervention and medication dosage for my patient - what the hell am I there for?


Might as well replace us with trained monkeys and be done with the whole deal.

And speaking of JCAHO, I have another post/rant lined up about it...

Bwahahaha!

What's the difference between an oral thermometer and a rectal thermometer?


The taste.