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. 

Whistle Blowers & Patient Advocates: When the Nurse Stands Alone

oil on unstreched canvas (detail) 2009 JParadisi

A colleague and I discussed the Winkler County Whistle Blowers case and our admiration for Registered Nurses Vicki Galle and Anne Mitchell. They brought the nurse’s role of patient safety advocate into the national spotlight.

My colleague is also a force to reckon with when it comes to patient advocacy. During our conversation she grew quiet and told me once, she had advocated for a patient without the support of her peers or administration.

The event occurred early in her nursing career, before she gained the skill and knowledge, which now empower her ability to act confidently as an advocate. In the end, she followed orders, even though they conflicted with her ethics. Decades later, she still regrets her choice.

I listened to her story, and tried to imagine her as a young nurse, uncertain and faced with a situation nursing school had not prepared her for. I imagined her alone and isolated, the only one in a nursing unit who felt, or more likely, spoke out loud the feeling that what was happening might not be best for the patient.

The Winkler County Whistle Blower case demonstrates that this kind of moral isolation still happens to nurses. However, it also demonstrates that nurses have developed resources for themselves and learned how to access them. These days, many hospitals have ethics committees and safety committees for reporting unsafe systems and behavior. Many hospitals have policies protecting nurses who refuse to administer treatments that conflict with their moral beliefs. Winkler County Memorial hospital fired Anne Mitchell and Vicki Galle when they used the hospital’s safety chain of command to protect patients, but the hospital and the doctor bringing charges against them found out this kind of punitive behavior is no longer tolerated by the court system or a majority of health care professionals. The Texas Nurses Association and the American Nurses Association said, “We are watching,” as did the Texas Medical Board. I’ve heard the conversations of doctors who ask why Dr. Arafile’s colleagues didn’t report his behavior. Why was the responsibility left to nurses? If any of these resources were available for my nurse colleague when she faced her dilemma decades ago, I would be surprised.

My heart breaks for that young nurse, facing an ethical dilemma alone and unsupported, with nowhere to turn. I told my colleague I hope she has forgiven that young, inexperienced, and frightened version of herself, with  her older, more experienced self’s compassion. I suggested that what she learned from that episode long ago has forged her into the warrior nurse advocate she is today, benefiting hundreds of patients during her long career as their advocate.

Obituary for a Cat



Lucas died a couple of weeks ago, in the midst of the preparations for The Acorn Contains the Tree, and “One more than four”.

Lucas was my husband’s cat, a grey American Tabby. I say “my husband’s cat” because the little sh*#   never accepted me into their relationship.  After eight years, we managed a fragile truce, because he realized he was dependent on me to feed him if David wasn’t home.

In the beginning, Lucas went out of his way to let me know he didn’t want me around. He’d hiss when I entered the room. On one memorable occasion, as I walked past him on my way to work, he lunged, claws drawn like tiny daggers, and drew blood from my shins, underneath the stockings he just shredded. I was late to work, after cleaning my wounds and changing stockings. I fumed about it to my coworkers, threatening to open the balcony door when I returned home, then turn on the vacuum cleaner (Lucas was afraid of it) and telling David that I didn’t know why the little beast had jumped to his death.

Of course, I never harmed Lucas. It’s a hallmark characteristic of most nurses that even when we face abusive behavior from patients, from physicians, staff in other departments, or from each other, we usually go out of our way to do what’s right. That’s why people depend on us. Even at home, I did what was right by Lucas. Not for his sake, but for my husband’s; at some point, I came to the realization Lucas and I had something in common: we both loved him.

So when Lucas began to fail, I encouraged visits to his vet to see if  his symptoms could be alleviated, to make sure he wasn’t in pain. At each visit (there were several) we were told that Lucas was an old cat. There was nothing to do about it. He finally went into renal failure, and that was the end. Lucas was sixteen years old,  93 in people years.

My coworkers asked if I was relieved, knowing how much trouble Lucas had caused. Thinking it over, I realize Lucas taught me a valuable lesson. He taught me how to put aside my own feelings for the love of another. I learned to make room for Lucas in my life, because I love my husband. Lucas helped me to become a better person, and for that I am grateful.

Reflections on Gonzo Living


Life is full of odd moments- you never know when you’re gonna get defiant.  Hunter S. Thompson

    A series of events occurring over the past few weeks have me reading about the life of Hunter S. Thompson. Mostly because I’ve been trying to understand someone I am close to, trying to understand his life choices. I don’t know if I can, but it’s part of my journey, and so I try.

   Also, I continue to ruminate on my last post, concerning torture (A Response to the Torture Memos, May 2, 2009). I’m troubled by the concept of “just following orders”, implied by the reference to “military grunts.”

   Following orders does not justify wrong actions in the profession of nursing. I’m not talking about making a mistake, regardless of the severity of the outcome. No one is immune from making a mistake.  I’m talking about the very few times in my nursing career I was given an order by a doctor to do something that I knew was wrong.  As a professional, as a human being, it is not okay to go ahead and perform the order because the doctor said so. It is my job, my accountability, to bring my concerns forth to the doctor and ask for different instructions. Usually, that works. Occasionally, it doesn’t and then I am placed in the position of gatekeeper for the patient’s safety. It is not comfortable to refuse a doctor’s order. On one memorable occasion, early in my career, I refused to give a medication to a child.  The doctor demanded my name, so he could “report” me to my manager, and I spelled it out to him over the phone “so that you get it right.”  A toxicity test on the patient confirmed my assessment and no report was sent to my manager.  Had I followed the order and the patient was harmed, “I was just following orders” would not have stood up in court as an excuse, nor would it have assuaged my damaged psyche.

   My friend’s choices, while difficult for me to understand, support his right to live life on his own terms, to make his own choices. Like Hunter S. Thompson, he didn’t have a high regard for authority.  I can learn from his example of self-empowerment.  While my own choices tend to be on the conservative side, I can learn from these two men the value of listening to my own conscience, my own inner voice. The path it leads me on might not be a safe one, but if I keep my integrity and self respect, then it’s the right one.

A Response to The Torture Memos

     Many people have their lives saved daily by surgeons who have learned the discipline of doing the unthinkable in order to accomplish the miraculous.

     Ask a trauma patient, transplant patient, or the parents of a child undergoing open heart surgery.

     Anesthesia and sterile drapes covering the usually unconscious patient certainly aids the surgeon in her duties. Health care providers go to work each day to help, not torture.

     Perhaps the answer to the paradox is in the body of the essay(The Surgeon and the Torture Memos, NY Times, by Dr. Pauline Chen http://www.nytimes.com/2009/04/30/health/30chen.html): Dr. Chen describes the torturers as “seemingly ordinary professionals”…”not just a rogue group of military grunts.” It is difficult for Dr. Chen to imagine someone like herself committing tortuous acts, but not a “military grunt” (also a human being), which I interpret to mean a person who is not educated in a profession. Does less education equate to less humanity?

     In my opinion, when we begin to differentiate humans into categories of “us/me” and “them/you”, we begin the processes of desensitization and habituation. This differentiation between categories of people allows us to find the justification to harm others, because “they are not like us.”

     Sometimes, people commit acts so horrific that it appears they have chosen to no longer abide within the constraints of civilized society, and justice needs to be rendered. For that purpose, we have a legal system.