Not Nurse Ratched

Rehab RN just wrote a great post about near misses with med orders. I think they should be called “near hits,” because they were actually misses, but no one pays attention to this opinion. I wish more nurses would write up their med errors and near-errors because I don’t know about anyone else, but I definitely learn from other people’s mistakes, and my patients benefit.

For what it’s worth, which may not be much considering I just made a scary medication error (the med error I made occurred DESPITE all this triple-checking, which is actually what freaked me out the most), I spend a proportionately greater amount of time on medications than anything else at work. I’m always the last one done passing meds because I obsessively check lab values, rates, IV bag labels, and so on, and then I go through each med with my patients and ask if any are new and if they have any questions. If they look dubious, I explore it with them. “Are you unfamiliar with this drug?” They usually shrug with learned helplessness and say something like, “Well, if my doctor says I should have it, I’ll take it.” Not necessarily. I go get the paper chart and go spelunking to see whether it was ordered, and often I can tell by the surrounding orders why it was ordered. If not, I usually don’t give it until I have time to figure it out. It obviously depends on the drug. If the patient swears she has NEVER taken amiodarone or Rhythmol, is in normal sinus rhythm, and has no obvious indications for it, yeah, I’m going to hold it until I get confirmation. If it’s a fish oil capsule, it’s not going to hurt her.

Anyway, I find errors by doing this. Not daily or even weekly, but regularly enough and scarily enough that I don’t want to rush too much with my meds, because there are about a hundred places in the system that a medication order can get jacked up, starting from the admission medication reconciliation and ending at me emptying a pill out of a blister pack. Almost all of them occur, though, like this: the physician writes the order, and it is scanned to pharmacy. They enter it incorrectly (wrong patient, wrong drug, wrong dose…). The RN scans through the new orders and notes them off in a hurry, so bam, that med is then on the MAR. Or the reverse. An order to hold a med is scanned but never gets taken off the MAR, so it’s still there, looking all official. The RN on the next shift then administers the med, assuming the RN before her correctly noted it, and discovers after the fact that the order was wrong. And there you have it. A medication error. (And usually the nurse who gave the med receives all the blame, yeah?)

Anyway, before I hand over the meds, I ask the patient, “Are we agreed, then, on what is in this cup?” If not, we go through them all again. So I’m usually still scrambling at 10:00 to get the last of my 9:00 meds out, but I figure screw it, better accurate and late than wrong and on time. My hospital uses the COWs (computers on wheels) for medications, so I drag these things around with me. They’re pretty handy and have med reference manuals integrated with the MAR, so I can sit down on the spot with the patient and read up on meds neither one of us can figure out a reason for. Often I’ll list off-label uses (ever read up on all the weird stuff they’re using allopurinol for these days?) and the patient says, “Oh yes! I have that condition.” (Witness me, frantically scribbling this vital medical history not given to us previously.)

In the best of all possible worlds I would have time to do chart checks before passing meds, but that will probably never happen. I eyeball the charts, but nurses have about 7 minutes per patient to get report and look up orders before we have to get moving or everything will start off late, and gosh do we HATE that. Boring the patients with medication dialogues is a good second choice, IMHO.

Unfortunately I think that although the most experienced nurse out there can commit a medication error, experience does play a role. Some of that experience comes through making the errors; there is really no way around it. I’m just now starting to develop these antennae and safety nets! So please, nurses, let’s share our lessons, tips, and tricks with each other. It’s really helpful.

I’ve gone from dreading work to puking when I have to go. Why? Because I am unable to not care that another nurse has randomly (to my knowledge) been gunning for me. She has yelled publicly at me, lied about my treatment (told everyone who would listen that, basically, I was incompetent), and badmouthed me to the day shift and to the patient’s family.

Let me pause to say I NEVER badmouth other nurses or the hospital to a patient or family member. They can complain so bitterly that ice cubes practically form in the room (often about this nurse, actually), and all I ever say is, “I’m very sorry you had a bad experience. Let’s work on making tonight better.” To do anything otherwise makes the hospital look bad.

My treatment was appropriate, so for once I’m not freaking out that I did something wrong. I’m baffled about why a grownup would behave in this fashion, and the tight lips and stony silences from people who until recently were friendly and helpful is devastating to me. Co-workers make or break a job when you get right down to it. Can this hateful nurse break me because she took a notion to? It seems so. Perhaps I lack the emotional maturity required to “let it roll off my back.” It’s not doing any rolling.

This here is the epitome of nurses eating their young. It is random psychological drive-by abuse and is probably common among nurses (other nurses I’ve consulted about the situation pause and say, cautiously, “Some nurses just need to build themselves up that way”…that might work temporarily, but surely people figure out eventually what they’re doing!). If anyone who reads this blog does it, I’ll hunt you down and make you read freaking nursing research textbooks until you freaking die. What does it TAKE to make nurses be civil to each other? No other profession tolerates this kind of behavior systemwide!

On the bright side, I do have co-workers who aren’t so easily fooled, and the behavior was so egregious that my boss was informed about the erroneousness and egregiousness of it, so it’s in no way like “everyone hates me and I’m going to go eat worms.”

Still, I tremble and can’t concentrate the whole time I’m at work. It’s no way to navigate a shift. I don’t do well with public shaming…I get ticked off constantly about small things, but it lasts about a minute and I get over it. I rarely get this upset about people being stupid and mean, because most people are one or the other. I hope it blows over (her meanness, my caring about it, or, optimally, both), but when I’m a tearful, shaky mess I seriously doubt I’m performing optimally at work. How to shake this off? I can easily shake off bad moods, snappishness, mean comments, and the day-to-day crankiness that go with being an adult, but an out-and-out smear campaign is a new monster to slay.

Am donning scrubs (the noncontroversial ones without the ties that cause my husband to snort with disapproval, for reasons no one understands), tying my hair back, and preparing for the first of my three night shifts. Generally this is the time of week when I have to stand behind myself with a cattle prod because I just. Don’t. Want. To go. Today I don’t feel that way; my attitude has magically been replaced for the moment with the philosophical attitude that either (1) I will have easy patients and time to sit down and read about hearts or (2) I will have difficult/busy patients and my shift will seem to be over immediately. It’s highly uncharacteristic for me to see optimism in all possible outcomes, so I felt I should record it instantly.

Listen up, new nurses, because your time is coming. I knew I was GOING to make a bad error, and so are you. Every nurse will at some point. Mine was a medication error and occurred despite my checking and rechecking the policy and having another RN verify the drug (the policy was unclear to me). I did everything “right” and still gave a life-threatening dose of a drug to my patient. Happily, the other RN doing the verifying had used the protocol before and said, “Hang on, there’s something wrong,” and we immediately took action. No harm to my patient resulted. It could have turned out a lot worse, and it’s the kind of thing that’s always made my blood run cold. We are so, so busy, and the drugs are so, so potent. It’s so, so easy to harm someone EVEN IF you are being conscientious. I thought I was. I checked my patient identifiers. I had other RNs check my boluses, lab values, and rates. I still overdosed my patient.

I called the physician and factually reported the situation (patient received xxx in error; do you have any orders?), and then…I wrote myself up by filling out a medication incident report. This sucked in a big way. The incident report form gives you a box to defend yourself, so I hope that the error will cause my facility to revise this particular protocol to clarify the part that caused my thinking to go astray. Change does not happen without nurses being accountable and filling out incident reports. I know this, yet I say again, writing myself up seriously sucked.

What was it like? When I discovered the error I had a nauseated moment, but in contrast to what I have predicted I would feel like, I immediately entered problem-solving mode and the competent nurse in me emerged full bore. I’m happy to report that concern for my patient completely overshadowed the desire to cover my ass; this tells me my priorities are in the right place deep down where it matters! Calling the doc and filling out those forms was no fun, but I felt philosophical about it. This is largely because my pod mate was an experienced nurse who gave me some free advice, which is worth passing along:

I don’t stew, fret, and beat myself up anymore for errors. Nurses make errors. The higher the acuity of the setting, the higher the acuity the errors will be. This is an inescapable fact. Each time I have made an error, I examine the error and determine one aspect of my practice I can improve to decrease the likelihood of that error happening again. Do I need to slow down? Do I need to clarify protocols more thoroughly? Do I need to be more insistent about needing help? And so on. And 10 years later, I make many fewer mistakes.

So I think I was able to step back, establish what I learned from this error (you better believe I will be double- and triple-checking ALL similar protocols in the future), and take appropriate action. I’m grateful that nurse was there because it gave me more of a solution-oriented mindset. (I was on the verge of seriously freaking out before that). Other nurses also drifted by to share their own error stories throughout the night to make me feel better. I work with some good people.

I called the next evening to check on my patient, and all was well. Now it remains to see whether I face repercussions from management. I’m nervous about that (I have moments where I’m SURE I’m going to get fired for it), but I am pleased with the way I repaired the error and took responsibility for it, and there is a strange and ironic freedom in having committed my first egregious error. (I don’t have to fear it anymore.)

The risk we assume as nurses in these times of scary patient ratios and higher-acuity patients is real and constant. Now my task is to learn how to be conscientious yet not be so crippled with fear of errors that I can’t do my job anymore.