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. 

Living With Our Mistakes & Holes in Our Socks

Knitting Two Socks at a Time on a Pair of Circular Needles. photo: jparadisi 2012

I’m learning to knit socks. If you read this blog regularly, you’ll recall learning to knit socks is one of my New Year’s Resolutions for 2012.  Since I don’t know what I’m doing anyway, I decided to learn the new method of knitting two socks at one time on a pair of circular needles, instead of one sock at a time on a single circular needle. Never mind only a few years ago I defined knitting as: making a tangled mess with yarn and sticks. Hey, I’m a girl who loves a challenge.  My audacity stems from years of the “see one, do one, teach one” on- the- job- training mentality most nurses rely on.

Fortunately, learning to knit socks two at a time is accompanied by patterns with clear diagrams and photographic illustrations. I found mine in Knitting Circles Around Socks by Antje Gillingham (Martingale & Company, publishers).

I’m happy to report I have successfully turned both heels. The most vexing problem has been confusing which of the four needle tips to use, then having to rip out and knit again previous rows after doing it wrong. I found one dropped stitch too, which is so far back at the beginning there is no way in hell I will rip out my work to redo it. I’ll simply learn to live with it.

If only nursing mistakes were as inconsequential. Who wouldn’t go back in time and fix the med error, rephrase the statement that made you sound dumb in front of coworkers, or treat differently the symptom, which turned out more significant than you realized at the time? Wouldn’t it be great if we could rip out our mistakes and knit them again like stitches dropped from a pair of needles?

We can’t.

Instead, I am aware of the importance my words carry when patients come to me with concerns or fears. I answer the same questions multiple times over the years of my career, but for the patient, their fears are new.  For everyone, I hope to get it right the first time: the right amount of compassion, the right understanding of the meaning of their words, the right kind of wisdom needed for a particular moment. If I get it wrong, coming across as abrupt, disinterested or intensifying fear rather than calming it, there is no going back to rip out stitches from the fabric created by my words and actions. They hang in our memories like dropped stitches; leaving an unsightly hole.

Nursing is more complex than knitting two socks with four needles. Often, there’s no way to go back and fix our mistakes. Sometimes the best we can do is learning from errors, acquire the necessary grace, and live with the resulting holes in our socks.

*Update: I finished knitting my first pair of socks last night.  See photo.

My First Pair of Knitted Socks! photo: jparadisi 2012


Of Med Errors and Brain Farts

I read the physician’s order carefully, looked up the medication in the nurses’ drug book, and consulted with our pharmacist before I gave it.  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.

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.” 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 a medication I am not very familiar with. That’s why I read the order carefully, looked it up, and consulted with our pharmacist. All I can determine about my confusion after giving the dose is that I had a brain fart. Somehow my eyes and my brain disconnected after I gave the medication, and the order unexplainably failed to make sense. That’s the best I can come up with: a brain fart.

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 that 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.

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.

She showed me how to string nursing tasks together like a pearl necklace, and eventually I gained the confidence needed to stay in nursing these past twenty-four 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.