Monday, June 27, 2011

Errors and Failure, Again

I've thought a lot about failure lately, since I am very good(bad) at it. This article about a nurse in Seattle committing suicide after she made a med error got my attention. Not just that she's 50, or had been in trouble with the powers that be at her institution (who sacked her after the mistake, which she self reported) but just the whole idea that she was at a loss as to what to do, that so much of her identity had been tied up in being a nurse.

Most health care professionals will take themselves apart after making a mistake--they'll go over it over and over, and change the way they do things. Institutions rarely have to punish one mistake--it's only patterns attached to one person that they have to pay attention to--but they often do.

Intimidating Dr. R. helped me with mistakes. I gave one of his patients one of the older oral antidiabetics at 2100 one evening--I just misread the MAR--my eyes skipped over a line. I called him with much fear and trepidation--OMG he is going to rip me--but he was relaxed--just asked that I be sure to write out an incident report and do an extra blood sugar check during the night. The patient didn't turn a hair during my shift and I never heard another thing about it. Meantime, I changed the way I read and handled the MAR and never made a similar mistake again. In fact the only other med error that comes to my mind is one time I gave a one time dose on the wrong day--thus causing me to make a new routine of writing the date on my "notes/brain" for both the evening and night of a 12 hour shift (19-07 or 20-08). Because of my earlier experience I had no trouble reporting the error--thankfully, it was a fairly benign drug--and there were no further problems.

Some drugs just require more vigilance. Ca++ and K+ because you can kill someone with them straight up. Heparin--because of bleeding going out of control. Insulin--because you can kill someone with it. This mistake was a decimal error--a power of 10. Pediatrics is full of this stuff. As time consuming as it is, you must double check your work. If an answer makes no sense, stop and do it again. That goes for letting a machine do your math. Rough out the equation for the x/kg/hour drugs--make sure the machine makes sense. Tables help with this--just recently I ran across my tables for NTG and such from HMW. Keepin' em. They are useful even if they are old as long as the concentrations match. And even if they don't completely, they help with that "sense" thing.

I feel this lady's sense of displacement--what are you when you are a health care professional in disgrace? You have all this good stuff in your head, and all the caring, and all the wanting the challenges, etc. etc. but no place to put it.

(Had to stop there...that's close to the bone.)

The Seattle nurse's mom, also a nurse (retired): "She ran out of coping skills."

Heartbreaking...and preciously close to the bone. Not being perfect should not run an otherwise competent person out of their chosen profession...

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