On this night we had a trauma and the experienced nurses were handling that, leaving a few of us newer nurses to manage the rest of the floor. One of my patients was having difficulty breathing, the ED doctor was concerned, I could see it in his face. He ordered an IV drip of magnesium and I started to prepare it. Back then we mixed most of our own drips, especially on 2nd and 3rd shift. As I pulled out the vials of magnesium I felt uncomfortable, there seemed to be too many vials. I ran it by one of the other new nurses and she thought it was OK. Now I realize that she was as overwhelmed as I was. My patient's condition deteriorated after we started the drip because I had overdosed him by a factor of 10. I alerted the doctor that his condition was worse, we stopped the drip and the patient was intubated. At this point I had no idea that I had made a mistake. God was watching us all that night, the patient recovered.
A little while later, while I was standing at the medication Pixis, a wave came over me. I realized what I had done.
I almost fell to the floor.
By now, the experienced nurse who was precepting me was out of the trauma. I went to her and she said to tell the admitting doctor. I walked over, sat near the hospitalist who was writing orders, took a deep breath and told her. She had just written an order for an IV with magnesium in it. She ran a pen line over the line, initialed it, put the pen down, turned to me and said, "It's going to be alright".
A couple of weeks later I was called to the office and Susan Davis, my boss, asked me if I realized what the mistake had been. I said yes and we talked about it. Sue said " I know you'll never make that mistake again". That was the total of my disciplinary action.
Today, our Pixis machines are in rooms instead of on the open floor, with it's distractions while you are pulling and mixing meds. The confusion over labeling of electrolytes in both milligrams and milliequivalents is minimized. We mix meds in the med room and are encouraged to have the pharmacy mix meds whenever possible.
That is what came of my mistake, because I had a boss who looked out for me and who corrected flaws in the process. There are still things we need to work on, such as help for less experienced nurses and appropriate staffing ratios that take into account patient severity and nurse experience.
Sue was a good boss, an advocate for her patients and her nurses. She now teaches Nursing in Virgina and works part time in an ED.
She recently sent me an email about a trend toward criminalizing nursing mistakes:
This article made me think about patient-nurse staffing ratios at WWBH. Nurses are now more than ever, at risk for legal actions. I firmly believe that staffing ratios and nurse's complex assignments set us up to fail. Maybe there is some information here for you to blog about. Always thinking about my family at WWBH.
The Criminalization of Nursing Mistakes