Of Med Errors and Brain Farts

 

Glasses ink 2019 by Julianna Paradisi

Giving an Unfamiliar Medication

I read the physician’s order carefully, looked up the medication in the nurses’ drug book, and consulted with a pharmacist before I gave it. Afterward, while signing the medication administration record (MAR), I read the order again, and I did not see the same dose I had read the first time.

Accountability for My Actions

Immediately the blood in my feet rushed up to my ears and I was lost in pounding waves of white noise. Fuck, fuck, fuck, I made a med error, and it’s a serious one! Of course, I didn’t say these words out loud. Instead, I carried the patient’s chart and the empty, pre-filled syringe to the nurses’ station. Putting them in front of the charge nurse I said, I think I just made a med error, a bad one. Look at the order and the syringe label. Tell me what I’ve done.

Relief: The Patient was Safe

She stopped what she was doing. She read the order and examined the syringe. You gave the right dose. You didn’t make a med error. Now breathe. The pounding breakers of white noise in my ears subsided into the gentle lapping of my breathing. Another nurse came to my side saying, I know exactly what you’re feeling.

I felt relief. My patient was safe. It was an unfamiliar medication. That’s why I read the order carefully, looked it up, and consulted with the pharmacist. The only explaination I have for my confusion after giving the dose is that I had a brain fart. Somehow my eyes and my brain disconnected after giving the medication, and the order unexplainably failed to make sense. That’s the best I can come up with: a brain fart.

Everyone Makes Mistakes

Later, my coworkers told me their stories of making med errors. We all make them. I didn’t know that when I was a new grad.

It is unbelievable to me as I type this, but it is true: in nursing school  I had an instructor who told our class that she had never in her thirty year career, ever made a medication error. Never. And I was young, and shiny, and idealistic enough to believe her. Seriously, I did. So when I made a medication error during the first couple months of my new-grad job, I was sure that I was not cut out for nursing. At that time, my coworkers didn’t gather around offering support like they did recently. No, I was written up, and had to call the pediatrician and tell him I had forgotten to hang a dose of ampicillin. He was more sympathetic than the day shift charge nurse back then. I made other medication errors too, nothing serious, but enough to consider quitting nursing during my first six months of practice.

Nurses Supporting Nurses

Then I met one of the best nurses I have had the pleasure to work with. For some reason, she decided to mentor me. I confided to her that I considered quitting nursing, because I made med errors, and that my instructor never had.  She laughed. If that instructor of yours never made a med error, then I’m thinking she’s too dumb to catch them. You are so crazy. Let me tell you about med errors… She was a great nurse, not a perfect one.

Eventually I gained the confidence needed to stay in nursing these past thirty-three years. I still make mistakes from time to time. I take responsibility for them. I learn from them. I am compassionate towards my coworkers when it happens to them. Nursing is not a risk-free profession.

And sometimes I have brain farts.

This post was originally published on January 30,  2011. I feel reposting it may be beneficial for nurses new to my blog. It has been updated. 

New Post for AJN’s Off the Charts Contemplates Nurses Missing Time with Our Families Because of Work

My latest post and illustration for Off the Charts, the blog of the American Journal of Nursing is posted. Heralding in the holiday season, it’s a contemplation of missing celebrations and family events when the needs of our patients require it.

Nurses Week Blog Post for Off the Charts

I wrote and illustrated a post for Nurses Week for Off the Charts, the blog of the American Journal of Nursing. It’s title, One in 4 Million is a reference to this year’s theme.

Has there been an influential nurse or mentor in your career?

Discovering Our Inner Lewis and Clark

Centennial Mills Snowscape II oil, wax on panel 2019 by Julianna Paradisi from an image of the 2017 Portland snowstorm

Those of us living in the Banana Belt of downtown Portland were spared the large amount (up to 8 inches) of snow dumped onto adjacent neighborhoods and outlying towns this past weekend.

Michelle Obama cancelled her trip to the Rose City because of the weather reports predicting Snowmagedon, after Seattle was blanketed in 5 inches of snow in only a few hours. Flights between Seattle and Portland were cancelled.

On Friday night we got a dusting of powder. Saturday morning, although air temps only reached 30° F, the sidewalks were clear except small patches of ice here and there, gone by noon.

The rest of the weekend was pretty nice, in terms of weather. In fact, the sun shone gloriously most of Sunday. I got a slightly pink sunburn from an hour’s worth of it shining on my face through the window during barre class.

The Internet guffawed mercilessly at the forecasters. Twitter and Facebook popped with snarky photo memes. Portland weather forecasters are used to the heckling, similar to our local sports teams when they lose.

Unpredictable weather is a part of life in Portland, treated like a personality participating in all social events like that crazy relative everyone suspects will act out but is invited to the wedding anyway.

It was reported with great humor that all the kale in Portland grocery stores had vanished from the shelves as panicked Portlanders stocked up on essentials to sustain them during the predicted week-long siege of Snowstorm 2019.

I hadn’t planned to go to the studio on Saturday, because we had tickets to see Michelle Obama. When she cancelled Friday afternoon, I still  didn’t plan to go because of the predicted inclement weather. When the snow accumulation proved slight, I still didn’t go because something inside me suspected foul play on the part of the storm: It was just an unexpected break in the weather; the really bad stuff could start any moment. These thoughts were somewhat fueled by reports and photos posted by Facebook friends attesting there was significant snow in selected Portland neighborhoods.

So I adapted. I scheduled barre classes instead of my weekend runs along the river. I did laundry. I meditated. I read my Tarot cards, and then journaled about what I thought the reading meant. I read a book. I took a nap. I made a pot of soup. I texted my husband who had to work the weekend. I told him I loved him and missed him, adorning the texts with happy faces blowing kisses emojis.

It didn’t snow.

On Sunday there were occasional light flurries of powdery snowflakes that melted on contact into tear drops falling from the railings of my deck. I took another barre class, but ventured no further from home than that.

We ate leftover soup that night for dinner.

The whole weekend was entirely anti-climatic.

I wasn’t alone in my feelings I discovered on Monday morning at work. When the topic of “the snowstorm that wasn’t” came up, and it did often, everyone said the same thing. They had been unable to reorganize their weekend plans to make use of the unexpectedly good weather. Almost everyone made soup. Lots of soup, too much soup for one family and they shared portions with their neighbors.

Disappointment was the most commonly expressed emotion. We had looked forward to being homebound by the snow that never fell.

In my mind, we were mourning our inner Lewis and Clark. A snowstorm gives us a cause to focus on as a community. But more than this, a snowstorm provides the opportunity to test our inner resilience, because in reality, Portlanders are closet survivalists. Note that stores ran out of kale, bread, milk and bacon. There were no shortages of parkas, snow boots, traction devices to put on the boots, or of generators, or snow tires, That’s because households already have these things, and every neighborhood has a neighbor with a big sturdy truck with all-wheel drive who will happily volunteer to take you to work at the hospital or wherever it is you need to be.

Oregon is home to the last of the pioneers headed west. Europeans discovered Hawaii long before Lewis and Clark arrived on the Oregon coast. In Oregon, we have travelled as far west as one can on the continent of this great country.

Those of us who came to Oregon from other places as young people came because we wished to connect with our inner Lewis and Clark; at least I did. I learned to start a fire from kindling I split myself from wood taken from the cord I stacked in the fall to get me through winter. I came because I love the change of seasons, the colors of fall, the damp, grey mossiness of winter that breaks into the brilliant smile of spring. I left the monotonous days of the state where it never rains to experience the full palette of nature.

Like my fellow Oregonians, I relish the threat of a Snowpocalypse for its gift of revelation: who I am, and what I am capable of.

And like my fellow Oregonians, I’m a little lost when the Snowpocalypse doesn’t arrive.

Happy National Bird Day: The Hummingbird

On my walk to work I looked up, which is somewhat unusual in that most of the time I am scanning the streets and sidewalks to avoid being hit by a car or bicycle, or colliding with another pedestrian, or stepping into an errant pile of dog poop.

But this particular morning I looked up. Above hovered a tiny hummingbird floating beside the very tip-top of a leafless tree silhouetted against the background of the cool gray winter morning sky.

After several seconds the hummingbird settled at the top of the tree. I took a picture of it, and then I made a drawing of the picture. It looks like this:

Hummingbird in Tree Drawing Julianna Paradisi 2019

2019: Days of Miracle and Wonder

These are the days of miracle and wonder 

-Paul Simon

 

 New Year’s Eve 2018 marked the twentieth anniversary of discovering a lump in my breast that proved to be cancer. So began the days of miracle and wonder that shaped the next year and a half of my life, transforming it in ways I could not have imagined at the time.

The Star collage by Julianna Paradisi 2018

2019 marks the ten year anniversary of publishing my first short stories in an anthology, followed by creating and writing this blog, JParadisiRN.

2019 follows a year of internal transformation. Thankfully, none are as dramatic or terrifying as a cancer diagnosis, surgery, and losing my hair, but they are significant enough to have opened my senses to new perceptions and possibilities as I completed the last year of a twenty-year cycle of personal and professional growth.

A former pediatric intensive nurse who’s transitioned into adult oncology nursing, I’m humbled by my survival. I know all too well some people are born to live only a few hours, days or a handful of years, and that cancer kills without remorse or discrimination the young, the bright, the kind. Others go on to live with chronic illness or metastatic disease. To survive an average lifetime is a miracle and wonder. It comes with a burden, or more rightly, responsibility.

I’ve written before I don’t believe in living a balanced life if balance is defined as To keep or put (something) in a steady position so that it does not fall. I still believe this. However, perceptions gained in 2018 have led me to expand my definition of balance to something more like a glass of world-class Pinot Noir: a thoughtfully crafted, satisfying blend of many parts chosen to complement the whole, and not elements distributed equally as though they are the wedges of a pie.

I don’t have a complete grasp of the concept yet, but I’m working on it.

At the end of cancer treatment, my transformation included selling or giving away much of what I owned, including my car. I sold my house and moved to Portland. I changed jobs. I took art school classes.

A couple of years later, I married my husband David.

I am very happy and comfortable in the life I’ve built during the past twenty years since finding the lump. Cancer turned into a catalyst for extraordinary personal growth. In 2018 it became clear to me that it is time to build on the foundation of that growth, moving beyond my comfort zone into whatever is next in my quest for growth and individuation. This time, the transformation is more of an internal thing, although there’s already been a couple of external changes reflecting the internal ones.

This blog post reflects an internal change too. I’ve written before that I write “To the So-What?” meaning in the past I began a post with a clear idea of how I would end it, and why I wrote it in the first place. Now I’m not sure I still believe the So-What is So Important. I am becoming enamored of process without attachment to outcome.

Let me repeat that last sentence: I am becoming enamored of process without attachment to outcome.

If you are a nurse reading this, you have an inkling of the size the internal changes. After all, what are nurses or health care providers without focus on outcomes?

Artists.

The Two Hands of Mindfulness

The little dish of crystals I keep on my desk. I made the little dish from clay. Photo: jparadisi 2018

Late on a Friday afternoon I sat on the floor of a shared office space in semi-lotus position, dismantling the fax machine to clear a paper jam. I needed to fax a copy of one more cancer survivorship care plan to a primary care physician’s office to meet my weekly quota before going home. If you work for an accredited cancer institute, and particularly if you’re an oncology nurse navigator like me, the phrase “survivorship care plan” is enough to cause heart palpitations, and maybe make your palms sweat. If the phrase doesn’t hold meaning for you, count your blessings.

Sitting before the fax machine in semi-lotus position, trying very hard not to break its plastic drawer while reaching for the piece of paper stuck in its maw, I considered the difficulty of practicing mindfulness in the controlled chaos that is health care. At that moment, I felt more akin to George’s father on Seinfeld, Frank Constanza, screaming “Serenity now!” than to the Dali Llama.

How is it I have the nursing skills to manage a patient’s airway on a ventilator, but am defeated by a piece of office equipment?

The stress is worse for nurses working at the bedside: For instance, how many times does the ED call to admit a patient to a nursing unit only to be told the unit doesn’t have a bed? I don’t mean a room, I mean literally, a physical bed? The admission is delayed while some poor night shift nurse traipse through hallways into the bowels of the hospital in search of a bed.

There are medication shortages to contend with, including the lowly bag of saline, diphenhydramine, and flu shots. These scenarios are not new to nurses. They are common occurrences we problem solve during the course of a shift, while managing the health and safety of our patients, documenting for compliance standards, and meeting accreditation mandates such as survivorship care plans.

Some days I’m more successful maintaining mindfulness at work than other days.  That’s why mindfulness is a practice. Practicing mindfulness requires compassion not only for others, but for ourselves. In fact, it’s my opinion that a lack of self-compassion and self-care contributes to a general lack of compassion towards others, fueling a hostile work environment. I keep a small dish of crystals on my desk at work to remind myself to stay in the moment.

As I sat on the floor in front of the fax machine, late on that Friday afternoon, a coworker returned to our office. She asked what I was doing, and I vented my frustration. She got down on her knees, and took a turn at dismantling the fax machine to get it working. She was successful. I faxed the care plan to the physician’s office, meeting my quota for the week. I got out on time to take my barre class, where we practice breathing and mindfulness.

Gratitude and compassion are the two hands of mindfulness.

 

 

AJN Best of The Blog Features Post by JparadisiRN

Manicure by Julianna Paradisi 2014

It’s an honor to have my post and illustration,  A Brief Meditation on Love, Loss, and Nursing, originally published on Off the Chartsthe blog of the American Journal of Nursing, featured in the February issue of AJN

Click on the link above to read the issue online, and find look for Best of the Blog, A Brief Meditation on Love, Loss, and Nursing, in the table of contents.

 

Down the Rabbit Hole

Down the Rabbit Hole, collage, 2017 by Julianna Paradisi

Why is it 2018 feels more like “2017, The Sequel, and not an actual New Year?

While I have one or two friends who’ve had an immediate change of luck, many more of us are experiencing 2018 as a poorly constructed, run-on sentence (or rambling blog post) with little progress or clear goals for the future.

Progress requires a release of perceived limitations, and expectations. The process of releasing creates tension similar to a snake shedding its skin, or a butterfly breaking forth from its chrysalis. Things become too tight and uncomfortable before breakthrough occurs.

Nearing the end of January, the growing and stretching feels more intense than in previous years, and I find myself sympathizing with Alice for choosing to follow a rather strange rabbit down a hole, without thought of where it would lead, or how she would return. “Don’t over think it, just do it.”

Choosing to go down the rabbit hole is not a characteristic of most nurses. Nurses like clear goals, something to steer towards, whether it’s gaining a patient’s trust by managing her pain, meeting discharge goals, or simply relieving a fever.

Measurable goals work in nursing. They’re admirable, and create safety.

* * *

Safety. What is safe?

As an oncology nurse navigator, and a cancer survivor, my patients and I grapple with this question daily: How to balance cancer prevention (safety) with an enjoyable and fulfilling life?

If you believe the answer is easily found in NCCN guidelines, and AJCC recommendations, you are most likely not a cancer survivor. Being a cancer survivor is “going down the rabbit hole.”

* * *

Being an artist and writer demands a willingness to go down the rabbit hole; a comfort level with uncertainty.

The challenge of life is learning to live somewhere on the continuum between safety, and recklessness.

Hank Stamper, the burly central character in Ken Kesey’s epic novel, Sometimes a Great Notion, about Oregon’s logging industry, argues towards recklessness:

“Hank would have been hard put to supply a reason himself, though he knew it to be true that Lee’s presence at the Snag tonight was important to him…maybe because the kid needed to see first-hand what kind of world was going on around his head all the time without him ever seeing it, the real world with real hassles, not his fairy book world of his that him and his kind’d made up to scare theirselfs with.”

* * *

Progress begins by asking questions.

What is safe? What is reckless? Should a predictable outcome dictate the beginning of a new enterprise?

An explorer would answer, “No.”

Alice returned from Wonderland, having viewed strange, new perspectives, and with a bunch of great puns. I assume she counted it a good experience, because she went back for a second trip Through the Looking Glass.

Here’s to going down the rabbit hole, and leaving 2017 behind.