Have you ever made a mistake in nursing?  Well, I have and want to share my experience, feelings, and outcome. When this happened, all that I kept thinking was, “Did I harm my patient?” Maybe that sounds familiar to you. I think we can all say that we went into nursing to help others, not harm them.   

I clearly remember the day that I made the mistake of running IV potassium too fast on a young patient. I was a seasoned nurse and not especially busy during the shift. I went into his room to hang one of the many potassium “runs” that we give to leukemia patients. 

Like usual, we chatted a bit, I hung his medication, and went on my way. Several minutes later he put on his light, and I went back into his room. He told me that he didn’t think the pump was running right and that his lips were numb. I looked at the pump and sure enough it was infusing at 450ml/hr. I immediately turned off the pump and my heart sank.   Of course I panicked. I thought I was going to be sick, but I needed to put my feelings aside and care for him. 

I sat on the side of the bed and told him that I had run the medication too fast, that I was sorry, and that I needed to check his vital signs and do an EKG.  I took a deep breath, trying to compose myself and did what I needed to do. Once I assessed that he was safe and had no ill effects, I hugged him and told him I was sorry. His response was kind and understanding, for which I was grateful, but felt I didn’t deserve.  

I spoke to my manager and asked if I needed to report this. She told me, “yes, that’s the only way we can implement changes to ensure that this will not happen again.”  I was really embarrassed, but also relieved that my patient had no ill effective.   I reported the error with hesitation and feelings of inadequacy as a nurse. I kept thinking, “how could I do something so stupid?” But I did and something needed to change in the future. 

Not long after my event, our hospital added a drug guardrails library to our infusion pumps, meaning that the rate of the medication is already programmed in the pump eliminating the potential for a different rate to be entered by the operator.  By sharing my own mistake, important changes were made to our nursing practice that would improve outcomes and provide a safer arena for our patients. 

I clearly remember that day years ago and use it as a teaching moment to show new nurses that we are all vulnerable and human. It’s important to understand that we need to have the courage to speak up and collaborate to make changes to ensure our patient’s safety. I tell them to always turn around before leaving the room and double check that pump rate.

Every time I share this experience, I still get that feeling of fear that I could’ve really hurt that young man. However, I remain grateful that being transparent about my mistake helped to prevent one in the future. Are you encouraged to report issues at your workplace or are you afraid of what may happen to you?  Please, take a minute and think about your patients. Understand that transparency is the only way we can provide safe, high-quality care. Admitting and reporting errors may save someone in the future.  My hope is that by sharing this intimate and embarrassing event in my nursing career, it facilitates an open, non-blame dialogue with others in order to maintain a safe environment for all of our patients.

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