Writing about an own mistake and carrying out self-criticism is always more complicated than doing so on a positive development. I have taken the “risky” decision to write about an error. Somehow remember involves reviving, doing present something that has happened, and not only in its rational content but also in the emotional one.

Empatize is a double issue: rational and emotional.

I try to draw attention to the importance of our work as nurses and the awareness of the total “deliverability” of the patient in our hands in a very important facet of the way we respond to health alterations in our healthcare environment: administration of drugs.

I wanted to make this writing because one can assume that a single mistake in the administration may occur in trainees with less experience, at the beggining of working life, perhaps. In my particular case there was not the ignorance of the drug in question, the administered dose, the time or the patient, or the route of administration (remembering the rule of five checks). It was only a mistake in the handling of a dual channel infusion pump. It was not a lack of knowledge of it but an error in the use of it.

The result, a bolus of an infusion of norepinephrine caused a peak hypertension followed by a marked hypotension in the patient. After the finding my error I was fast, stopping the pump, extracting blood from the light to minimize the circulating drug and quickly reporting the situation to the responsible physician. However, the error was already there and norepinephrine, stubborn, continued to make its effect of alpha and beta adrenergic.

 

In those moments had more than one sick person in the box.

For me, the mistake has made me reflect once again (as if they had not done so on countless occasions) and I wanted to share this reflection through a writing that can eventually fall into the hands of a person who could see far this kind of errors.

All professionals in any field can make more or less mistakes in his/her professional life, as well as more or less brilliant performances. We all know or we make a mistake, but what is the specificity of the nurse error? Obviously we are the last link in the chain of drug delivery (leaving aside the issue of an “autonomous” patient therapeutic adhesion).

Throughout my professional career are no countless, but also few situations in which I have personally called the attention on a drug scheduled to which was allergic the patient, about an excessive dose due to an error in fact or otherwise, a pharmacological incompatibility or forgetfulness in the pattern of a drug. Nothing exceptional. It is simply my duty.

On the other hand, with my mistake, nothing/no one could attend me; the specificity of the working nurse, among others, is that: being at the head of the bed, on the other side of the lumen of the catheter, closing and opening routes of administration, to the command of an infusion pump buttons.

Three hours later after that error, yet restored completely (except me), I could see my shed more bipolar when I spent an emotional valley to a situation of calm and well-being (similar to a warm sun to sunset). It was that, slowly, leaning on a cane, the elderly husband of the patient went into the box. Her granddaughter was behind. Both with that mixture of sadness and astonishment that relatives have to enter in an ICU. Sad to see your family member with multiple cables and tubes for all the body and amazement to discover a universe of devices and screens with capricious lines of different colors on which it is assumed that they dictate the vital status of your loved one.

Sitting in a part of the control from where I could observe the situation I was happy with their visit.

Many relatives of patient intubated in ICU seek you upon entering the box because they want to somehow channeling their desire to communicate with their loved one through the professional nurse. In a sense, in those moments we fulfill a shamanistic function. After watching for a few moments to relatives in their first evolutions in the box and “require” me by the look, I went to the box. Although, rather, I think in this case it was upside down, I came into the box because I wanted to talk to them and somehow help me to connect me with her to… ask them forgiveness?


Although I was emotionally exhausted, I ended up happy my shift to have solved the situation and be aware that my vocation nurse was “bomb-proof”.

The particularity of Nursing mistake
Metas de Enferm feb 2011; 14(1): 73-74007474
Francisco Cebrián Picazo
Nurse of Special Care Unit at Hospital de Hellín (Albacete).
E-mail: fcebrian6@gmail.com