Monday, October 16, 2006

My first incident report

Last week I had a little problem.

I work nights and on this particular night, I didn't get the rest that I am used to getting. I came into work, not feeling like I was going to have an great night. I had a choice of patients. The other more experienced yet still new "graduating in the top 5% of her nursing class" nurse said she didn't want the patient that I was getting because of her "poopy tracing" and God forbid she should get stuck with a potential crash. (Serves her right because her patient had an even "more poopier" tracing than mine!) I got report and coming in, this patient had already had one late deceleration on her tracing, which in my line of work is indicative of a non-reassuring fetal status. Also the baby had passed meconium that some consider to be indicator of non reassuring fetal status, (or possibly a mature digestive system, we are still waiting for the evidenced based explanation). Another way to say non-reassuring fetal status is fetal distress, but we NEVER say fetal distress because attorneys have a field day with that sort of thing in the event of a deposition.

So, her labor wasn't progressing. She had been 6 centimeters for almost 4 hours which can be considered arrest of labor and lead to a c-section. So it was my responsibility to increase her pitocin. The therapeutic benefit of pitocin is to generate contractions that dilate the cervix and facilitate the descent of the fetus into the birth canal creating a situation conducive to vaginal delivery. I followed the protocol, I assessed the fetal heart rate, I assessed the intensity and regularity of the contractions. The contraction pattern was irregular and non-functional, which justified my actions. The baby's heart rate indicated that he was tolerating the labor well. The patient's lungs were clear to auscultation and her blood pressure was within normal limits.

Our protocol is to increase the pitocin 1-2 milliunits every 15 minutes to a max dose of 36 milliunits per hour. At the time she was at 14 milliunits or 28 ml/hour based on the dilution of the medication in normal saline. My intention was to set the pump at 30ml/hour or 15 milliunits. The family was talking to me, the room wasn't lit very well and somehow I set the pump for 90ml/hour or 45 milliunits/hour. I walked out of the room to get ice chips for the patient. She had an epidural, so she wasn't giving me that "Oooo" that lets me know I did something wrong. It ran at the wrong rate for about 5 minutes when I noticed it and immediately changed it. I came out and told one of my nursing colleagues and she said note the chart of your error and monitor the patient. For 45 minutes nothing happened. Everything was normal.

Then the doctor went in to do a vaginal exam. All of the sudden, I looked at the tracing and noticed that the baby was having a little decel. I thought that the monitor came off so I went into the room to see what was going on. The patient was on an internal monitor. This decel was REAL! I was freaking out inside. I turned the patient from side to side and gave her oxygen. IT DIDN'T COME UP. The heart rate was 59 bpm. The doctor was still at the bedside. They gave her medication to stop the contractions and we turned off the pitocin. The heart rate finally came back up. Whew! I told the doctor of my error.

In that moment I was embarrassed because when something is going on everyone is listening and looking at YOU. Every doctor on the floor and ever available nurse was there. This is good because if you need help there is someone there. At the same time you kind of feel bad. If there was a bad outcome, it can be neither confirmed nor denied that it was a direct result of my wrong doing. I filled out an incident report. For the rest of the night I didn't want to touch her medications. Then the doctor said that I needed to give her more pitocin so that the patient could have contractions because her labor pretty much stopped. I did, but I was scared to death. I especially hate the fact that everyone knew about my mistake. I was the talk of the unit. I am sure everyone has made a mistake. Mine was minor, but I will have my eyes open from now on. Maybe someone will learn from it making my public humiliation worthwhile.

After that, one of the older 20 year veteran nurses walked me through each medication adjustment, which made me feel much better. The patient dilated to 10 centimeters and 100% effacement at the end of my shift. I imagine she delivered without too much trouble, except the fever that required antibiotics.

DiVa...Feeling not so confident but thankful for the angel over her shoulder!

1 comment:

overactive-imagination said...

I can't imagine how scary that must have been for you. I'm glad everything turned out okay.

That is one more thing I will be hypervigilant about. Luckily this was done in practicum on a dummy last week or I very well could have killed my pt. It was my very first time passing oral meds and I was a nervous wreck because of course I was being "checked off" on this skill.
The instructor handed me the MAR and told me that those would be my meds........I gave them.....everyone on the page, totally disregarding what TIME they were supposed to be given. Of course I failed and had to schedule a re-do.
At first I was really angry with my instructor...she should have told me I was giving 1000 meds, I've never done this before. Then I was really angry at myself....but mainly that I was under a deadline to have this practicum checked off.
Then I realized just how bad this could have been in a real life situation. It wasn't my instructors responsibility to tell me to read my MAR correctly even if it was my firsts time and I was ashamed that my only concern was my "time" and not my mistake.
I realize now that I am glad that I didn't fly through this particular practicum with flying colors because it had taught me something and it is also a mistake I know that I will NEVER make again.

Sorry for the long post but I can only imagine how much you have beart yourself up over this. Everyone is fine and no one was harmed as a result so don't beat yourself up too badly just chalk it up to your first mistake and rest assured that it's not something you'll ever do again.

Dawn