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. 

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.

 

 

How I Became a Nurse Part III: It’s An Ongoing Process

The Christening Gown (From Cradle to Grave: The Color White) by jparadisi

One shift, Roz and I worked alone. That night, there were only two patients in the pediatric intensive care unit. Roz was charge nurse. I sat at the console charting, with the hypnotic QRS tracings of sinus rhythm in the background. Roz charted at another desk by the door. The door opened and a man I’d never seen before entered. He walked past Roz, to me. He identified himself as the pediatrician for Roz’s patient, and asked who was the charge nurse.

“Roz is in charge. She’s taking care of your patient.”

He continued addressing his questions to me. “How’s my patient? What’s his blood pressure?” “I don’t know,” I reinforced, “Roz is your patient’s nurse, and she has his chart. She can answer your questions.” I looked quizzically to Roz, who briefly looked up, then put her head down, intent on charting. The doctor continued. “I want to know the I and O. Is the patient getting enough pain medication? Are his parents around?” I didn’t get it. I remained confused until Roz walked over and handed me the chart. Suddenly, I understood. My anger flared then turned into a cold lump in my stomach. I had to control my voice as I answered his questions from the chart.

Roz nursed circles around me. I owed it to her that I was in the PICU and this physician wouldn’t talk to her because of the color of her skin. I only spoke to him because of his patient, a child. He scribbled some orders, gave me the chart, and left. I felt traumatized by his overt racism, and because he directed it towards Roz, my friend. The cold lump in my belly morphed into nausea.

“Roz, I’m so sorry. He’s an ass.” Her eyes betrayed her feelings, but her words were calm.  “Jules, I don’t blame white people for this. That fool is an ornery, nasty soul no matter what color his skin is.”

Decades later, Dr. Racist remains a painful memory. Dr. Racist was never seen again in the PICU. He was a blip on our screen, nothing more. His disappearance prevented Roz and I from doing more than complain to management.

Becoming a nurse is an ongoing process. Certainly, a nurse’s expertise grows through attainment of knowledge and skills, but it is more than that. Becoming a nurse also includes learning when to speak up and when to let something roll off your shoulders. Like everything else she taught me, Roz was better skilled at this than I. I am not a qualified authority on racism in nursing, but the National Black Nurses Association, and minoritynurse.com are two educational resources by people who are.

My treatment by Sister Sebastian was workplace bullying. What happened to Roz is workplace bullying taken to its sinister extreme. It is so universal that the successful TV comedy series The Office uses it for its premise. However, when nurses experience workplace bullying, we are usually in the midst of work requiring responsibility for the safety of others. It’s hard to stand up to rude or disruptive comments when your patient’s condition is rapidly deteriorating or you are in a patient care area. Bullies know this, and use it to their advantage. I think this is what makes workplace bullying particularly demoralizing for nurses:  often, we must choose between defending ourselves and protecting our patients.

I have one strategy, developed over the years, which I find effective. When I overhear a coworker berated by another in either language or tone of voice, I go stand next to that person. Usually my quiet presence is enough to cause the offending person to stop. Occasionally it is not, and the offender asks, “What do you want? Why are you here?” I reply, “I’m just wondering if everything is okay over here. Do you realize everyone can hear you?” So far, this has always stopped the abuse. It’s particularly effective if more than one nurse stands by.

Becoming a nurse is an ongoing process. I am still learning.