My essay to my Clinical Professor after nearly making a medication error on Tuesday; March 19th 2013:
On September 14th,
2010, a registered nurse by the name of Kimberly Hiatt accidently administered
ten times the amount of calcium chloride to a critically ill infant- she gave
1.4 grams instead of the prescribed 140 mg. The eight-month old infant died
five days later. Hiatt was fired, terminating her 24 year career as a RN.
Termination is certainly a problem for everyone but committing a grievous
medication error will leave everyone involved shaken, it will cause us to be
doubtful of our competency as health care providers, it will cause us to be doubtful
of our future in the career, to feel devastated for the harmed or killed
patient and their families, along with feelings of shame, embarrassment, guilt,
depression, and punishing self-blame. As I read the story of Kimberly Hiatt’s
mistake and the proceeding unraveling of her life that followed which
eventually led to her suicide in April of 2011, I feel I can still only imagine
the devastation that she must have been feeling. I feel bad for her, I really
do, and at the same time I can see myself being in a situation similar to that
of her’s because I nearly made a medication error, and would have committed one
had my nurse not caught it right then and there. And as you know, afterwards
during our meeting, I was seriously doubting if I have the right mentality,
attitude, personality, and competency to perform in this career. Making that
simple yet serious error brought up thoughts of whether I have the right
reasons to be in nursing as well. As I have remarked, my main reasons of
motivation for pursuing a career in nursing are not ones of complete altruism
but more out of selfish desires of what I want to pursue in my life-
travelling, adventure, etc. And as I write this now, I know no one can give me
an answer that will satisfy me because no one knows.
From doing research, I am reminded of how many medication
errors occur every week alone in the United States. Medical errors are the
sixth leading cause of death in the United States, and even more shocking is
the fact that, the number of deaths as a result of medical errors fill up four
jumbo jet passengers every week. To just put it out there in terms of numbers,
it is estimated that 40,000 harmful and/or fatal errors occur each and every
day (Statistic as of 2012). As I read these statistics to myself, there is a
small part of me that wants to say that because these occurrences are happening
every single say, with decently high frequency, that medication errors should
not be that big of a deal, but I know that type of thinking is inexcusable and
cannot belong in nursing or any healthcare career. As I think over the events
of my own near-miss incident, I was rushing myself out of fear of being seen as
incompetent and slow. Additionally, I did not run through the five rights
protocol with cautiousness. To be honest with myself, I had a “nothing bad will
happen” type attitude, was not thinking of the dangerous consequences that could
happen, and did not have a 100% focus in the present moment to ensure I had
engaged in the five rights. To make matters even worse, I failed to remember to
follow my hospital’s protocols of scanning the meds before opening them. As I
write this, I wonder where my mind wandered at that time. I remembered to scan
the first four medications because my nurse motioned me to, but as she was talking
to the patient and trusting me to continue following protocol, I seemed to fall
into an automatic cycle of telling the patient what the medication I was
opening was and forgot to scan them. It was only until my nurse came right
beside me to where I was opening the medications did I realize I did not even
scan more than half of them. Right then at that moment I experienced that
feeling of incompetency and a loss in my confidence. I remember thinking to
myself, “how in the world did I forget to scan more than half of the
medications?!” Something so simple, yet, I forgot. During our talk, I really
felt that if I don’t develop terrific habits of checking the five rights
carefully and thoroughly, “My god, I’m going to be killing someone literally
like this and my own life as well. Forget about all my dreams outside of
nursing, I’m going to be fired, license revoked, devastated, broke, sued, and
may even face civil or criminal charges against me. All this studying and years
of hard work for this?!” I don’t know how other students have reacted to
near-misses (since I am the first one you’ve had), but these feelings of shame;
incompetency; guilt, from the very real reality of causing harm or death to a
patient; and years of hard work down the drain in a second, overwhelmed me to
tears. I really do understand that you are wanting to help me here. I
understand that you are already being lenient with me as you technically needed
to write me up. I really do understand that you need me to do more work than
others because you are concerned that I am in a precarious position right now.
In terms of what I need to do to prevent medication
errors, I need to be very careful and alert when taking out the medications
from the Pyxis machine and checking with the MAR that I have the right patient,
the right medication, the right dosage (so the right number of capsules like I failed
to do), the right route, and the right time. From my research, I have also
found two other rights that are very beneficial, and these are the right reason
to giving the medication, and the right response, meaning, checking to make
sure that the medication is having the proper and expected desired effect. I
very much agree with your opinion that I need to slow down and not rush when
performing any nursing related intervention. I need to realize the seriousness
of the profession I am training to be in and ask questions to get answers
regardless of my fear of being seen as incompetent, because it is the very
irony that is causing me to make mistakes! It is my fear of being seen as
incompetent, that I rush procedures in hopes of not being judged as slow. It is
due to that fear that I do not always clarify all the questions I may have
lingering in my mind. I’m terrified of being seen as incompetent! And it’s
killing me and stunting my development. I hear about the other students doing
different skills, and I feel like I’m behind. It can be frustrating. (Written
as of Thursday; 3/21/13)
(Writing
this part as of Tuesday; 3/26/13) Writing this after the emotions of the event have more
or less dissipated, I believe this lesson was worth learning. It is a lesson of
slowing down and being careful. It is a reminder of the danger that is involved
in the profession. Looking at this event from afar, I am reminded of a quote
that speaks truth to me and it goes like this:
"Stuff is going to happen to us all. It's how we respond to that, that's going to make the difference. Remember everything that happens is neutral until you give it a meaning. Feel that distance between event and response. Often, we can't understand the meaning of events until time has passed and we look back."
- Brian Kim's MIT of March 21st, 2013
This is such an empowering quote. At the time I was writing the first few pages of this essay, I was feeling down and in the dumps over my mistake. Now as I write these words later, I feel a sense of gratitude for learning this lesson early. Medication errors are mistakes that can happen to anyone and to come away from this experience with a sense of cautiousness and safety is worth it and will remain to be worth it as long as I remain careful. Sometimes we need an event of seriousness to wake us up. I surely have been awakened and will keep this experience in the back of my mind to see that this doesn’t happen again. Thanks for helping me learn this lesson. I sincerely appreciate it.
My Ejournal for Simulation (The Week After):
Taking into account of the painful
lesson of last week, I went into simulation with the attitude of slowing down
and carefully carrying out my interventions. I learned from watching others’
simulation scenarios that completing a thorough head to toe assessment is
absolutely crucial in being able to choose the proper interventions that meet
the problem of the client’s pathophysiology. Many times, we would rush into
choosing an intervention that is based off an incomplete assessment and
therefore, a lack of data, to get the entire picture of what was happening to
the patient. An example, at the beginning of a head to toe assessment, if we
find that the patient is experiencing increasing shortness of breath and
difficulty breathing, we may assume that we need to turn up the oxygen and
administer a bronchodilator to help with the SOB. This reasoning is based off
of the notion that the patient is experiencing bronchoconstriction, however,
without listening to the lung sounds, listening to the patient’s complaints,
and obtaining a full set of vital signs, we may not find out that the actual
cause of SOB is being caused by fluid build-up in the lungs and a result of
heart failure and pulmonary hypertension. This example may not be the best
example but it gives an idea of the importance of obtaining all the relevant
data before deciding to choose an intervention. This may be hard to do when the
patient is in pain and is obviously in distress but without the proper data to
make a determination, our interventions chosen out of haste may have little to
no beneficial effect on the patient and can even aggravate the situation. In
today’s example, the albuterol can cause increased HR and bronchospasms in a
patient already experiencing tachycardia. So far, going to simulation has
really given me a shot in the arm and confidence in my assessment skills and
rationale of how to help the patient. It is something that I needed after last
week’s error. I’ve learned two valuable lessons in the past two weeks and I
hope these lessons will only serve and protect me and the patients in the
future.
