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Nursing Mistakes: Learning & Moving On

April 7th, 2010 by – Marijke Durning

Nursing Mistakes: Learning & Moving On

Mistakes: we’ve all made them, we’ve all found them. After all, we’re human, right? The extent of the errors vary widely from medication or treatment errors, errors in judgment to errors in misinterpreting an order, but they are errors nonetheless.

Although we know how to do things properly or we should ask for help if we don’t understand something, there are times when things go awry and before we know it, a mistake has been made.

Medication Errors

As students, who didn’t sweat bullets when it came to being afraid of making a medication error? The International Council of Nurses did a study that showed nurses play a key role in helping prevent medication errors by doctors and pharmacists. However, despite doing our checks, right drug, right patient, right time, right dose, right route –mistakes still can happen, usually because we are interrupted or distracted.

Oddly enough though, I found that most of these mistakes happened when it was quiet, not when we were busy. It seems that when we are busy, we know that mistakes can happen, so we’re ever vigilant to prevent them. But when it’s quiet, it’s easier to get distracted and easier to let your guard down.

The Forgotten Patient

Have you ever forgotten a patient? One time, on a medical unit I was on, the charge nurse forgot to assign one of the patients. To make things worse, this patient’s room was off to the side, not one that you would go by often unless you meant to go to her room. As a result, the patient slipped through the cracks and didn’t receive care for most of the shift. Luckily, that patient was independent enough not to need constant care, but we were all horrified that this could happen.

As nurses, we are busy with our own patient loads and our own worries, so it may not be obvious to us that someone isn’t receiving care. After that incident, every time I was charge nurse, I was fanatical about being sure every patient was accounted for every shift.

Procedure Errors

Procedure errors happen. We’ve all heard horror stories of the wrong limb being targeted for amputation, but it’s also smaller things that can happen. I remember once taking over a patient with an NG tube to suction. But, when I went to make my nursing assessment, there was nothing happening. The reason? The suction machine wasn’t plugged in; the cord was still coiled around the holder. No wonder the poor soul was feeling so nauseated.

The next day, I quietly told the relatively new nurse about her error – she had transferred the patient from one room to another and forgotten to plug the machine in – but she vehemently denied forgetting. Making a mistake is upsetting, but denying it doesn’t change the fact that it happened. I have to admit, I never trusted her again.

Mistakes shouldn’t happen. Unfortunately, mistakes are made. The best we can do is learn from the errors and make every effort not to repeat them.

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Posted in On-the-Job Fears

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