The other day I was working in the Peds ER. I had a toddler getting an IV bolus after 3 days of vomitting. I checked the IV when I initiated the fluids. The patient was to be discharged after the bolus completed (only took about an hour). I came back when the bolus was one to disconnect it, remove the line, and give discharge papers.
To my surprise, it appeared that the entire bolus infiltrated. I was so sick over, I felt terrible. It had only been 1 hour since I checked. The site was boarded and the child was sleeping soundly on his stomach when I went to take it out. Since it was just NSS I removed the IV and applied warm compresses immediately.
I feel terrible about it, but it had only been 1 hour. The child ended up being admitted to monitor for compartment syndrome. I guess I just need some encouragement that we all make mistakes.
Danielle
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December 4th, 2008 at 9:38 am
Yes, we definitely all make mistakes. For sure…I just had a medication error a couple of months ago. And trust me, I am definitely more cautious now. You are still a great nurse. Everyone just makes mistakes
December 5th, 2008 at 3:37 am
Absolutely, we all make mistakes, no matter how careful we try to be! You would never intentionally hurt anyone, and if you weren’t a caring, conscientious nurse, you wouldn’t be beating yourself up over it! It means you care, & just like Melissa said, it will help you be even more cautious in the future. Just don’t ever try to lie about it or cover it up! Handling it promptly & honestly promotes trust that you ARE competent. You’re a great nurse!
December 5th, 2008 at 1:15 pm
In an ideal world my hospital taught us to check on IV lines every twenty minutes. I have been guilty of leaving it one hour as well as it’s just been so busy. I don’t know where the hospital came up with the figure of 20 minutes, but it’s not a bad idea. It only takes a second to check the infusion/rate and the site.
It’s just an idea, but it might help.
December 6th, 2008 at 11:20 am
Dear – you just learned a very good lesson. That is what you take away from this experience. Thanks for sharing, maybe others will learn as well. Celebrate that accomplishment, and trust me, I know how you are feeling.
December 6th, 2008 at 8:40 pm
*hugs*
We all make mistakes. All we can do after the fact is learn from them. I’m a senior year nursing student, and last year I was caring for 2 patients, I pulled meds for one patient, got distracted, and ended up giving the meds to the other patient. I realized the mistake a few minutes later when I was putting her MAR back and notified my prof. Luckily, the patient who received the wrong meds didn’t have any allergies or adverse drug interactions, but I still felt terrible, especially as I was sitting there filling out the med error report and then afterwords I had to go and tell the patient that I had given her the wrong meds. I’ve never felt so horrible in my life. I sat down and cried for a long time. It took me forever to forgive myself afterwords. But I also learned from the experience, and it has made me much more vigilant when passing meds.
As the others have mentioned, just take it as a valuable learning lesson and know that even nurses are only human and so we do make mistakes.
December 6th, 2008 at 8:42 pm
Dear Heart- we all mess up once in awhile. I have been a RN for 35+ years. I have made 2 med errors in my career (at least two I know about)- the last one was last Spring! I was sick for days about both. The thing is, we need to try to use each as a learning opportunity. This child probably was fine. THE MOST important thing is that you realized your mistake, feel awful about it, and you will learn from it. I want you to know that I am impressed that you are admitting this mistake, care deeply for the patient, and are reaching out to other nurses for support. Now, please try to forgive yourself, figure out if there is anything at the worksite that needs to be changed that CAN be changed to minimize these errors, and then try to work to make the changes you can. You are a terrific nurse, I am sure…..I am hoping that all my students are like you when they graduate.
December 9th, 2008 at 5:49 am
WHEN RUNNING AN IV ALWAYS CAUTION PT/ PARENTS TO WATCH FOR S/S OF INFILTRATION. OFTEN THEY CAN GIVE YOU A HEADS UP EARLY. YEP WE ALL HAVE BEEN IN YOUR SHOES AND AS I ALWAYS TELL OUR STUDENTS YOU CAN LEARN SOMETHING NEW IF EVERYDAY SOMETIMES IT IS ONLY WHETHER THE COFFEE IS FRESH. STAY OPEN, BY SHARING WE CAN LEARN FROM EACH OTHER. I’VE NEVER IGNORED ANOTHER MISTAKE OR CLOSE CALL, I TRY TO TAKE IT TO HEART.
December 15th, 2008 at 7:05 am
Thanks for sharing that we are human and do make mistakes. You are doing the best thing to ease your conscious. I also made a medication mistake with an infant. I gave the wrong dose of Prevacid. I admitted my mistake both to the family and my employer. I learned a lesson and am cautionous when giving meds.