January 15, 2012 | American Society of Registered Nurses®
Journal of Nursing

When Nurses Make Mistakes

SAUSALITO, CA (ASRN.ORG) -- Last year, a Seattle nurse named Kim Hiatt committed suicide. Ms. Hiatt’s death came nearly seven months after she had given an unintended overdose to an infant heart patient, a medical error that was said to have contributed to the child’s death days later.

Ms. Hiatt had been a nurse for 27 years and had often cared for the 8-month-old girl during the child’s stay in the pediatric intensive care unit of her hospital. She had probably drawn up the right dose of the drug hundreds of times in her career. But once, she made a life-changing error. A baby died, and she was suspended, then fired from a profession she loved. And now she’s dead.

This story makes me feel sick — sick for that dead baby and her parents, and sick for Kim, who must have felt so alone with her pain.

It’s a pain that I, and every nurse and doctor, can relate to on some level. We’ve all made mistakes, most of them small and inconsequential to the patient’s health, but sometimes the mistakes are serious. Most of the time, our errors don’t amount to much because the hospitals where we work have put in place systems of checks and balances to be sure serious mistakes don’t slip through. But even when your mistake is caught and a potential crisis averted, you are left with the knowledge that you almost harmed a patient you were trying to protect.

My worst mistake ended up not mattering at all, but it still pains me to think about what could have happened as the result of my error.

I had been working a full shift but agreed to stay later than my scheduled 12 hours so the floor wouldn’t be short-staffed. Hospital error rates go up when nurses work more than 12 hours, but I’d done it before, when needed, and all had been fine.

One of my patients had a new diagnosis of cancer and was going to the operating room to get a permanent intravenous line placed in her chest. During morning rounds, the medical team had decided to delay the patient’s chemotherapy by a day, but late that same afternoon the doctor in charge told me that the chemo would, in fact, start that night.

I was caring for three other patients and hadn’t planned on anything new coming up. But now the patient would soon be coming back from the operating room and I had chemo orders to check, double-check and send to the pharmacy. Then I had to administer the treatment.

After I completed all my checks on the doctor’s orders, I saw my patient, who had returned from the operating room. She was very hungry, but I couldn’t get a meal from the hospital kitchen, so I took out bread and peanut butter from our pantry and made her a sandwich.

While trying out her new IV line, I discovered it had a strange leak. It was a problem that neither I nor the charge nurse had ever seen, and sounded unusual enough to the surgeon that he came back to the hospital from home — in a sweatshirt and his Merrells — to make sure all was well with the line.

Everything turned out to be fine, and I gave the patient her scheduled chemotherapy.

I went home exhausted, but flushed with the satisfying feeling that I could do it all — I was Super Nurse. Until the phone call came the next day.

There was a dose of chemo still in the drawer. The patient was supposed to get two drugs, and I had given only one.

Holding onto the phone, I actually bent over with the pain of surprise. With chemotherapy, the timing of the drugs can affect the effectiveness of the treatment. I worried that the patient’s treatment had been compromised and that she might die from her disease because of my mistake.

I felt that I had broken a sacred bond. As nurses, keeping our patients safe is always our most important priority. If my error endangered my patient in any way, I had completely failed in the most fundamental obligation of the job.

But I was lucky that my mistake ended up not having any clinical consequences. The second drug did, in fact, need to be given within a certain time frame relative to the first drug, but there were hours left on the clock for the second drug to be given. The patient would be fine.

The next day at work, I saw the doctor who had written the chemo orders. I’m certain my face was drawn with shame, and I apologized. The doctor was instantly reassuring, saying the data showed no difference in treatment effect if the second drug was started at the same time as or slightly later than the first drug.

And then this doctor said something that made a huge difference to me, and it’s a sentiment I think about often. “A situation like this can build trust, Theresa,’’ he told me, “because the patient knows we’re being honest.”

He also said that the situation had been fully explained to the patient. Amazingly, the patient knew of my mistake, but once she learned that it didn’t matter in terms of the course of treatment, her only concern was for me. The patient told the doctors that I had done a good job caring for her that evening, and she didn’t want me to be fired.

I was touched by her reaction, and it made me think about all the nurses, doctors and pharmacists who are all trying to do such a good job. But there are times when we don’t, and then we have to live forever after with the knowledge and the consequences of our own failures. And sometimes other people, like the poor parents of that baby in Seattle, have to live with the consequences of our failures too.

My penance was twofold. I printed out article after article on that particular chemo regimen and read them in a bizarre form of intellectual self-flagellation. I also swore that I would never again stay late on top of a 12-hour shift, and I never have.

Because now I know that I’m not Super Nurse — I’m human just like everyone else.

 

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In this Issue

>When The Nurse Is A Bully

>Demand Growing For Giving Birth At Home

>Need Sleep? Stay Out Of The Hospital

>When Nurses Make Mistakes

>Health Insurers Making Record Profits As Many Postpone Care

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