I wish I could sit here and say human error in the nursing profession is a very rare occurrence. I wish I could say I have never made a mistake. I wish I could say you will never make a mistake.

I CAN’T tell you that you wont make a mistake, I TOO HAVE made a mistake, YOU WILL AND MANY OTHER WILL MAKE A MISTAKE.

Research says that health care providers involved in medical errors experience significant emotional turmoil. Nurses and physicians report feeling anxious, upset, guilty, depressed, and scared after an error, often for prolonged periods. Medical professionals frequently experience emotional distress after medical errors and often do not receive support for coping with this distress (White, Waterman, McCotter, Boyle, & Gallagher, 2008). Nurses don’t commonly ask for support when dealing with an error. Many nurses want to forget the incident, don’t want their coworkers to know about the error and suffer in silence.

As a nursing educator/instructor, I commonly tell my students, orientees and coworkers “mistakes kill children”. (I say children because I now work in pediatrics) Some might feel my comment is extreme, but the reality of it is true. Let me tell you my story. Here it goes…

When I was in my 1st month of orientation, my preceptor and I had an incident in which a child died due to a preventable incident. This child had a horrible brain injury and would not survive we all knew that, but at the time the child was stable. Then it happened, the child started to deteriorate, we called the family to say goodbye, their child was dying. As the room filled up with physicians and other nurses the chaos rose to high levels. We were adjusting the many inotropic medication drips we had running, we were pushing sedation and paralytics. We were frantic to stop this child from herniating her brain before her family had a chance to hold a warm hand to say their final goodbye. I was new, though experienced, I was scared. The room was packed with staff. Alarms were going off, physicians and nurses were barking orders…then the alarm that changed it all started to beep. The epi drip had run dry! I stood at the end of the bed wondering what the hell to do, as the experienced nurses buzzed around pushing their skills to the limit. My co-worker yelled “someone make an epi drip NOW”! Vitals were unstable, all we could do was attempt to use the epi that was still in the IV tubing to sustain the child until the epi drip was made. With nerves and adrenaline running high, the epi was slowly pushed into the patient, but with the lack of epi, then the surge of epi, was it was too much for the child to endure or was it just the event itself? The child’s vitals skyrocketed, the ICPs rose, then dropped. It had happened, the child herniated, coded and died.

The shock was overwhelming. The feeling in my gut was sickening. The last moments for the family to hold a warm hand to say good bye was gone, stolen by a dry epi drip. I can still feel that heart wrenching, sadness as I write this now. When everything was said and done, tears were cried, we pulled ourselves together and then the most powerful thing happened.

The door to the room was closed, my preceptor and I prepared the body for the morgue in silence. The Attending physician entered the room quietly. He looked distraught and defeated then looked at us both and said, “where was your watchful eye”? That question always stayed with me. Even though there were many qualified people in that room, even though it was inevitable this child WAS going to die with no question, it was our duty to manage those drips, we were the expert of that patient in that moment. That’s right…where the hell was my watchful eye?

I share this story with you because we as nurses should learn from our mistakes and the mistakes of others. Do you think I have ever let any drip run dry since then? Do you think I stand back and let others run the show when my patient is taking a turn for the worst even if they are more experienced? Absolutely not! The patient is my responsibility, I need to be the expert in that room, I need to know my patient inside and out, I NEED TO HAVE A WATCHFUL EYE, you need to have a watchful eye.

Mistakes happen, we miss things, we are human. We have many safeguards in place, but the onus is on you to make your environment as safe from human error as possible. Share your mistakes, own your mistakes, let others learn from your mistakes so it doesn’t happen to them. Don’t question whether you should give up nursing after making a mistake, embrace it and strive to make yourself a better nurse, a stronger nurse, a more educated nurse. Cry if you need to, analyze the situation, ask for support if you are having trouble dealing with a mistake or error. Don’t shut down or run from it!

With every negative experience there is a positive learning experience. To the physician (you know who you are), Thank you.

Thank you my dear friend Regina, who is one of the most amazing nurses I know. This topic is very important.

Coffee time, stay strong nurses you are the heart of the medical system.

Jen

References:

White, A. A., Waterman, A. D., McCotter, P., Boyle, D. J., & Gallagher, T. H. (2008). Supporting Health Care Workers After Medical Error: Considerations for Health Care Leaders. JCOM, 15(5).