Posted by: medicblog999 | September 18, 2010

A mistake to end a career

I was reading through my usual multitude of favourite blogs the other day when came across an interesting post from Steve Whitehead over at the EMT Spot. Steve writes a little about a cardiac arrest call that he was at that didn’t go quite to plan.

I would argue that he didn’t actually make a mistake, rather had a loss of focus for a little while (which happens to all of us at times), but the 4 points he puts forward to help us get past a mistake certainly struck a chord with me and made me think back 15 years and to an incident that virtually ended my nursing career before it even got started. I share this with you all to show how NOT to deal with a mistake and show that as Steve says, it very much does happen to all of us at some point in out working lives.

I’ll split this into two parts. First in this post, just the facts, then I’ll discuss what I think I did wrong and how I could have managed the situation better in Part 2. This is a pretty big disclosure for me but hopefully it may be helpful to someone out there…

I was a newly qualified registered nurse on my first ward from leaving nursing school. I had moved away, to work down the country in my ‘dream job’. Things seemed to be going really well.

I had always had an interest in palliative care and cancer nursing, so with 10 months left of my training I started to apply to various hospitals around the country for jobs on oncology (cancer) wards. I was over the moon when I got offered a position and looked forward to starting what was sure to be a prestigious nursing career………..

I had been on the ward for about a month, and at the time of the incident was the only qualified member of staff on the unit (the Sister in charge and other nurse had gone off for their breaks). On that day we had 27 patients on the ward in various stages of treatment or palliation of symptoms and I was in the middle of doing the drugs round. I was happily pottering around dishing out the medication and keeping an eye on a number of patient’s chemotherapy regimes that were running. I had been going for about an hour when I came to one of my favourite patients on the ward, Sam.

She had a fairly aggressive cancer but her treatment was going well ; she always had a smile on her face and I used to love sitting on the end of her bed and having a chat at various times of the day. The chemo that she was having was particularly nephrotoxic (which means that it really isn’t good to have it in her body for too long as it can damage the kidneys) and because of this she had to have a big dose of a diuretic both before and after the chemo (so as to get the kidneys working full out before the chemotherapy, then flush the kidneys out after the chemo). I had already given the chemo and was going to give the post chemo diuretic when I noticed that I hadn’t given the pre chemo dose.

My world stood still.

I felt sick.

I started to sweat.

I had that horrible feeling when you get that sickening feeling in the pit of your stomach.

All I could think of was Oh Shit! Oh Shit! Oh Shit!

Then the questions started to come…

“What should I do?”

“Have I damaged her kidneys?”

“How do I tell her?”

“How did this happen?”

The one thing that didn’t even cross my mind was “Do I need to tell anyone?”

I had made a mistake, and in my mind this one was a big one. I ALWAYS own up when I do something wrong. Some may say that this is a character flaw; some may say this is a good thing. All I know is that I cannot cope with the guilt of knowing that I have done something wrong which may impact on someone else. (Looking back, I know that this was the final trigger in a sequence of life events that started me on the road to OCD, which I have written about before).

I couldn’t think of anything else other than what I had just done, and I knew I had to do something straight away.

I shut the drugs trolley and went into the office, bleeped the consultant on call and called the cafeteria to ask for the Sister to return immediately. I sat in the office staring at the phone when the ring startled me back into the reality of the situation. It was the consultant.

I explained what had happened and waited for the onslaught of what was sure to be a major blasting……..However, none came my way. The Consultant was gracious, caring towards me, and told me that he would be straight up to sort it out. Shortly after I put the phone down the Sister and the other nurse returned looking a little flustered and asked me what was wrong.

I explained what I had done, and again, they were pretty cool about it and said that we could sort this out and that I should go and finish the rest of the drugs round. I went back out to the trolley and moved onto the next patient, but as I passed Sam, she stopped me.

“Are you okay Mark?”

“Yeah, yeah fine thanks Sam”

But I wasn’t, I felt sick to the pit of my stomach and if anyone was going to tell her what was going on it was going to be me.

“Actually Sam, im not ok, I feel dreadful”

I proceeded to explain what had happened and that her consultant was coming up to see her. I reassured her that everything would be ok and apologised to her. She was amazing.

“Don’t worry Mark, its ok. I’m sure everything will be just fine……..and….thank you for telling me”

The consultant arrived and had a quick chat with me to see exactly what I had and hadn’t given. He again reassured me that she would be fine and try not to dwell on it. He went off and took some bloods from her to check her kidney function tests. It turned out that she had to stay in hospital for an extra day so the doctors could keep an eye on her kidneys, but over all she was absolutely fine. I on the other hand was far off being fine.

I was left looking at the drugs trolley.

I couldn’t do it.

I couldn’t hand out any more medication. What if I made another mistake, what if my next mistake was more serious? How could I live with myself if my actions harmed some one else?

It may seem a big over reaction to you, but at that moment my world felt like it was collapsing.

What would I do if I couldn’t be a nurse?
What would I do if I couldn’t care for people?

I went into the office where Margaret, a lovely kind Auxiliary nurse was sitting. She asked if I was okay and I just crumbled. I cried and said I couldn’t do this anymore. The sister came in and tried to reassure me a bit then sent me home for the rest of the shift.

I was to come in for my next shift the following day and ‘get back into the swing of things’.

I struggled to sleep that night, and went into work the next day feeling more than a little anxious. I kept trying to tell myself that I was being too hard on myself and needed to get things into perspective, after all Sam was going to be fine and everyone makes mistakes right?

As I arrived on the ward, the Sister in charge asked to see me and asked if I was alright and said that she would have to write a report about what had happened but that it was absolutely nothing to worry about, just procedure. She would also see if there was anything they could do to help me if I felt I needed some help. Other than that I was to get back to normal and carry on with my duties.

It wasn’t long before I needed to do the drugs round again.

It felt like a nightmare. Every patient I went to, I ended up triple checking, then checking again and again to make sure I had the right patient and the right medication.

This wasn’t normal safety checks, it was the start of OCD and it marked the end of my ward nursing career. I seriously couldn’t handle the responsibility of doing something as simple as handing out some medication to my patients

I walked off the ward a couple of hours later, packed up my things in my room that I was renting and headed up the motorway to return home.

I ran away.

I never worked as a nurse on a ward again.

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Responses

  1. Talk about a heart shattering moment. Thank you for sharing something like this.

  2. Powerful stuff.

  3. I want to thank you for sharing this for many reasons, not the least of which is that harming a patient (not that you did!) is my worst nightmare. I lost a patient many years ago partially because I got lost in a strange city enroute to the hospital. I left EMS for a while because of it. I have always wondered how other people would have felt in my place. Now I know that others probably would have felt like I did and that means alot.

    • Im sorry to hear about your struggle Mark, but glad you found your way back to the profession. Tough times indeed, but at least you stuck in there in the end!

  4. I hate making mistakes. Even when it really didn’t end up hurting the patient. It’s knowing that you screwed up and it had the potential to cause serious harm to your patients.

  5. Reading your post brought that sense of dread that I felt the day I found out I’d overdosed a neonate with a 10x dose of morphine in a NICU. He was ventilated and critically ill so it wasn’t discovered until later in the day when two other nurses made the same mistake. I did all of the proper safety checks and followed procedure but to this day I still can’t figure out how four RNs and two doctors all made the same error. Mine was the first in the chain though and, to my knowledge, was the worst mistake I’ve made in 27 years of nursing. The baby survived and went home and I went on to tell the story over and over again. It was painful to admit I’d made such a glaring error but it was the one way I could do something to try and prevent it from happening again. If I, as an experienced charge nurse (who was normally meticulous in calculations and procedure) could make such a huge error, I wanted every other nurse to know it was possible for them to do the same. New procedures in medication packaging would have stopped that from happening now but there’s always a way for things to go wrong when humans are involved. But Mark, I will never ever forget how hard it was to go back the next day and like you, how close I came to calling it quits right there on the spot. Thank-you for speaking up and showing the rest of us that have made similar (or worse) errors that we are not alone.

    • Wow, that sounds like a tough time too. I, like you, also believe that sharing the difficulties that I went through can show others that its ok to struggle through tough times in our careers and reinforce that we are not perfect and all make mistakes at some time. Even though I regret how I handled it, there is still a learning opportunity to take from my experience.

      I would also like to thank you for sharing.

  6. We are all human. We cannot be perfect 100% of the time. We put a lot of pressure on ourselves. I our jobs we feel we should be 110%. Our biggest think to learn is that we do make mistakes and we learn from them. The patient was not harmed in this circumstance. You being a good nurse is why you are being so hard on yourself. If it didn’t bother you then I would look into not working again. I do not think this is a reason to quite your job. Maybe taking a break to deal with your feelings and talking to a pshycologist might help. We have to have help understand why we feel the way we do. I really hope that you reconsider quiting you job for good. You are good at what you do just always remember that!

    • Hi Karen,
      Thanks for your words of kindness.

      Just to emphasie though, this happened 15yrs ago and whilst greatly affecting my career choices, ultimately didnt stop me from me from succeeding in pre-hospital care. I’ll discuss this more in part 2.

  7. I can relate, only on a paramedic level in field.

  8. Mark, I read this on the first day you posted it and started to write a comment. That comment turned into a post and, rather then posting it right away, I let it sit over the weekend. I went to look at it this morning and I couldn’t post it. It’s personal, it shows weakness, and it makes me doubt myself – all things that I have problems with. Although I can’t bring myself to tell my story; know that you are not alone in this.

    • Hi Lizzie.

      I completely understand and hope I havent made you delve into areas you didnt want to go to.
      I firmly believe that sharing can help though, especially with people who arent too close, but also know that some things just arent for the public domain.

      If you do want to share though ( in a more private forum ) you can always email your post to me and I may be able to share our experiences a little more.

  9. As always Mark, a truly passionate post. I think the biggest issue here is that of accountability. Many providers would not have the guts to cop to a mistake like that and, in the end, do the right thing. The strength to admit that a mistake was made should not go unrecognized. I can certainly say that I’ve made mistakes in my career and that I’ve always made an effort to learn from them. Thanks so much for sharing something difficult and painful like this. I hope it makes as big an impression on the rest of the community as it has on me!

    • Thank you mate.

    • And thank you for the mention and kind words in your blog post, http://510medic.com/2010/09/20/lack-of-accountability/ You are spot on when it comes to thinking about taking the medical model of morbidity & mortality meetings into EMS. I would love to see something like that as long as it was in a supportive and nuturing environment.

  10. I consider myself a very conscientious and professional career paramedic. One day a 7 year old came in to the ER needing intubation. I calculated the size of the tube to be 5.5. I went to the cart picked out a tube and proceeded to attempt to intubate. With a clear shot of the cords, I was trying to pass the tube but was finding resistance. A resident told me the tube was too big, but I told him 5.5 was the right size. As I was attempting to pass the tube, the resident looked at the wrapper, and told me the tube was in fact a 7.5! I could not believe my ears. This was a typical intubation of which I have done hundreds of without aver making a mistake. Thankfully there were no adverse effects, except to my pride. Since that day, every time a check an airway kit, I mark the tube size CLEARLY on each package and advise all of my co-workers to do the same. That happened 14 years ago, but I still sometimes get chills up my spine thinking about it.

    • What is becoming so clear in these comments is how we are all at risk of mistakes, but hopefully our profession attracts the kind of people who will try to turn a negative into a positive! In my case, 15years ago, I just dont think I was mature enough to get past the initial trauma of making that mistake.

  11. Thank you for sharing this. I too have had a time where I had to rethink my job. I was so upset I went over and over in my mind the steps leading up to it and could not figure out why I pushed this dose. I thought long and hard about leaving my job in fear of hurting someone. I believe this was a major change in me I was no longer prideful thinking I did everything right all the time instead I was humbled knowing that I am human and error is possible and this is why it is important to not go through the motions but instead go over it in your head as you are doing it.

  12. The loss of a nurse has obviously been the ambulance service’s gain.

    Whilst the incident obviously unnerved you, you’ve come back strongly. Let’s face it, not only do you give drugs but you have the authority and training to decide what to give and, within limits, how much. You don’t have better trained support with you either.

    bloody brave of you to tell us too.

  13. […] I finished part one, I ended with me walking off the ward and leaving my job as an oncology nurse. This was only two […]

  14. […] shortages. Mark Glencorse put it all on the line (Doesn’t he always?) with his story about a mistake to end a career. Michael Morse gave some thought to roadside memorials in his post Aftereffect and in another kind […]

  15. […] why do I bring this up? Well I’ve been thumbing through Google Reader and happened along 999 Medic aka Mark Glencorse, who had a very powerful message about making a medical error. You should read it before […]


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