Weekly Actual Nclex Question Bank

Sunday, February 20, 2011

What To Do After You've Made A Mistake

Everyone makes mistakes. It's what you do afterward that makes you an honorable human being and a good nurse . . . or not.
Nursing school doesn’t really teach you how to be a nurse, it just gives you a glimpse into the world of nursing and the NCLEX gives you a license to learn. If you’re smart, you’ll learn something new every day of your career. If you’re very smart, you’ll learn how to handle those moments when you’re very, very stupid.

Everyone makes mistakes. Everyone. There are no perfect people, and anyone who would have you believe they ARE perfect is a damn liar. So know from the very first moment you put on that name badge that says “RN” or “LPN” or “CNA” that you, too will make a mistake. Mistakes are an inevitable part of life and an inevitable part of nursing. What matters isn’t that you’re perfect; what matters is what you do after you’ve made that mistake.

Recognize your mistakes. I’ve known a few people who were so convinced of their own perfection they couldn’t recognize their imperfections. If they did it, it must be right. If you’re not willing to admit the possibility that you might make a mistake, you’re unlikely to realize when you’ve made one. The very first thing to do when you’ve made a mistake is to recognize it. The second thing to do is to admit it -- to yourself, to your charge nurse, to the provider, to your manager and ultimately to the patient.

It’s amazing how few mistakes actually kill patients or even cause them permanent injury. Some do, we all know that. But if you recognize your mistake, admit it and immediately set about to minimize the damage, most mistakes are merely a bump in the road rather than a career ending or life ending catastrophe.

I worked with a nurse I’ll call Maria. Maria was a lovely person -- beautiful, funny and smart. She also lacked integrity. We worked in SICU together years ago, and one day I was in her room with her, helping her to turn her fresh-from-the-OR cardiac surgery patient. As we turned him, the monitor started to alarm and we looked up in horror to see his heart rate slowing down and passing 30 on the way south. The surgery resident was just outside the room and responded instantly to my involuntary utterance of “Oh, S%&#!” There were many interventions, but the one I’m talking about was the order to give “point one milligram of epinephrine.” Maria grabbed up the amp of epi I handed her and pushed the entire thing -- one milligram.

Suddenly we had the opposite problem. The patient’s heart rate picked up -- slowly at first, but rapidly gathering steam and the rate on the monitor was over 15o when I looked up from the code cart. From no blood pressure and a flat art line, we suddenly had a pressure of over 250 systolic. And climbing. “How much epi did you give?” shouted the resident.

“What you said,” replied Maria, hiding the empty syringe from view. “I gave what you said.”
“How much was that?” countered the resident.
“I have what you said,” Maria insisted, despite clear evidence to the contrary. And she never budged from her story. Never. The chest tubes were suddenly full of blood and the pleurevac overflowing. As we whisked the patient back to the OR, there was a trail of bright red blood in his path. Maria’s mistake didn’t kill the patient because of the quick thinking and quicker actions of that surgery resident, but I never trusted her again. Neither did the resident, who is now head of cardiac surgery at the hospital where Maria still works.

As soon as you recognize that you’ve made a mistake, tell the appropriate person. It’s not enough that you recognize your mistake, you have to do everything you can to prevent, minimize or mitigate the damage. If you’ve made a medication error, tell the physician. There may be -- usually is -- something that can be done. Narcan can reverse a narcotic overdose , protomine reverses a heparin overdose and if you’ve given too much insulin you can follow it with sugar whether it be a can of real Coke or an amp of D50. You’ll need a doctor’s input and a doctor’s order.

Once you’ve done what you can to help the patient, take a moment to think through the process that led to your error. Were you moving too quickly? Distracted by family members? Couldn’t read someone’s handwriting? Whatever it was, you need a firm understanding of how and why you made your error and an idea of what you’re going to do differently next time to keep it from happening again.

Then tell your manager. There are right ways and wrong ways to tell your manager, but whatever you do, tell her before she finds out from someone else, especially if it’s a big mistake. Call her at home, email her or whatever. There’s nothing worse from a manager’s perspective than being blindsided by the person who comes to confront her about some mistake made by a member of her staff.

As an example of the WRONG way to tell your boss about a mistake, David once defibrillated a patient in normal sinus rhythm because he mistook artifact for a lethal arrhythmia. He was new to ICU, and some artifact LOOKS like V tach, V fib or even asystole. David shocked his patient in full view of an entire team of doctors and a couple of nurses who were all yelling at him to stop. “Oops,” he said with a laugh. “I shouldn’t have done that.”

No one else was amused.

You want to make it abundantly clear to your boss that you realize you’ve made a mistake, that you understand the consequences were or could have been enormous and that you’re profoundly sorry. You also want her to know that you’ve thought about how it happened and how you’re going to make sure it doesn’t happen again. Few bosses would tolerate David’s responses to a mistake, but I can tell you from personal experience that you can survive the second with your job and your license intact.

Lastly, forgive yourself and move on. That’s often the most difficult part of the whole process. But not moving on condemns you to relive your mistake over and over and over again. It undermines your confidence, destroys your sleep and makes it more likely you’ll make more mistakes. That’s a vicious cycle.

I won’t say I’ve completely forgiven myself and moved on . . . yet . . . but I’m working on it.

NCLEX for RN - Leadership and Management (11-15)

NCLEX for RN about Leadership and Management

11. A nursing student is developing a plan of care for a client with a chest tube that is attached to a Pleur-Evac drainage system. The nurse intervenes if the student writes which incorrect intervention in the plan?

a) position the client in semi-fowler's position
b) add water to the suction chamber as it evaporates
c) tape the connection sites between the chest tube and the drainage system
d) instruct the client to avoid coughing and deep breathing

12. A nurse is caring for a client who has just had a plaster leg cast applied. The nurse would plan to prevent the development of compartment syndrome is instructing the licensed practical nurse assigned to care for the client to:

a) elevate the limb and apply ice to the affected leg
b) elevate the limb and cover the limb with bath blankets
c) place the leg in a slightly dependent  position and apply ice to the affected leg
d) keep the leg horizontal and apply ice to the affected leg

13. A registered nurse (RN) is supervising a licensed practical nurse (LPN) administering an intramuscular (IM) injection of iron to an assigned client. The RN would intervene if the LPN is observed to perform which of the following?

a) changing the needle after drawing up the dose and before injection
b) preparing an air lock when drawing up the medication
c) using a Z-track method for injection
d) massaging the injection site after injection

14. A nursing student develops a plan of care for a client with paraplegia who has a risk for injury related to spasticity of the leg muscles. On reviewing the plan, the co-assigned nurse identifies which of the following as an incorrect intervention.

a) use of padded restraints to immobilize the limb
b) performing range of motion to the affected limbs
c) removing potentially harmful objects near the spastic limbs
d) use of prescribed muscle relaxants as needed

15. A registered nurse (RN) is observing a licensed practical nurse (LPN) preparing a client for treatment with a continuous passive motion (CPM) machine. Which observation by the RN would indicate that the LPN is performing an incorrect action?

a) places the client's knee in a slightly externally rotated position
b) keeps the client's knee at the hinged joint of the machine
c) assesses the client for pressure areas at the knee and the groin
d) checks the degree of extension and flexion and the speed of the CPM machine per the physician's orders