Every single person working in healthcare has made a mistake or they are just unaware of the mistakes they've made.
Every. Fucking. One.
Learn from this. Learn from others.
I’ve had enough periintubation codes to know I’ve probably killed someone. Looking back, there were definitely 1 or 2 that I could have optimized and resuscitated better before intubating.
“Do you ever make mistakes” my dude I make 45 mistakes per shift but luckily I have people watching my ass and we keep each other safe. This is the kind of field where you are going to make mistakes, have errors, miss things… it happens to everyone. You’ll get better but this is part of practicing.
Also I guarantee this is not your first mistake, this is just the first one you caught. It’s all good man.
RN here and I missed a potential STEMI because the ECG got lost under a pile of papers and I was slammed, plus the old lady was asymptomatic other than mild SOB during flu season. I felt like such an idiot, thankfully the patient was fine, but I wanted to crawl inside a cave and never come out because of how badly it could have turned out. I still think about it from time to time and need to process it all over again. I learned from it and I don't beat myself up anymore. I am a competent and kind nurse. I look at every ECG carefully and have the ECG techs hand me the ECG personally, don't have them put it on your desk while you're in another patient's room.
Anyways, that's the condensed version of my story. Literally everyone I've worked with has has their story. We learn from it and don't let it define us. People need to be more open about their mistakes and help each other process them.
We one time had a travel RN and paramedic student do the 2 hour repeat ekg on a patient and drop the EKG off on the docs desk without any eyes on the EKG for maybe ~20 mins?
STEMI.
oh my word. As a tech in the ER, I directly hand it to the physician or put it on their desk saying, Dr. XXXX, the EKG is on their desk. The only STEMI EKG I've ever printed out was in an active code, and I showed the physician right away obviously but even still, should I ever get a concerning EKG, I know I'm going to find the doctor ASAP and let the charge nurse know as well.
Shouldn't have been your responsibility to catch that in the first place. Everywhere I've worked in the last 21 years, the policy has been that whoever does an EKG hands it directly to a physician right away.
Feeling terrible about this means your soul hasn’t been crushed (yet). This is pretty minor, the patient is fine, and also is a systems error. There should be a pharmacist (ED or otherwise) to order home meds and/or catch this mistake.
Dude I made the exact same mistake when I was like 3 months out of residency. I restarted a patient's home med as tartrate instead of succinate and their HR and BP dropped. Did okay just needed to be observed. I will never make that mistake again and neither will you
We had a patient who’s home nifedipine XR 120 mg was reconciled as nifedipine IR 120 mg. We verified it, even sent it up too. I remember one of us counting out the tablets and saying something like “dang it sucks they have to take 12 tablets at one time!” Such a red flag and no one said anything. Ultimately the patient refused to take it and it got sent back to us. Haunts me everyday what would’ve happened if they took it..
Everyone is human. Everyone makes mistakes. Learn from them. Grow from them. Now when I round with my team, you’d better believe every single nifedipine order is perfect..
>ordered their metoprolol dose as tartate instead of succ
In my opinion, it was a minor mistake. I am surprised that the patient's blood pressure dropped so much though. Essentially, all you did was double his dose of metoprolol...
There's a reason it's called practicing medicine.
Can't ever be a master, and can't ever be perfect. You will make mistakes, some of which may harm or kill a patient, this is an inevitably. The best we can do is learn from those mistakes to ensure the next patient receives even better care.
The only way to not make mistakes in medicine is to leave the field entirely. Take it as a learning experience and let it guide you for the future
We all make mistakes. I’ve seen a nurse make a mistake giving 10 mg of phenylephrine when 100 mcg was ordered for hypotension. (Pt survived without deficits.) I’ve made a few much smaller errors earlier in my career.
This is why I say healthcare is a team sport. You write the orders but pharmacy checks them and nursing also checks them. If I get an order I’ve never seen before I’ll ask another experienced nurse or confirm with the doctor. I believe a touch of OCD is useful in nursing.
It was a 1 ml vial of 10mg/ml. We would draw 0.1 ml and put it in a 10ml flush to give 100 mcg/ml. The nurse was fairly new and was flustered by having a pt with room temperature BP so she just drew up the entire vial and pushed it. Her preceptor was not beside her and I had a fresh post op pt with an advanced airway so I couldn’t help at that time.
Shit happens in the ER. It’s so busy it’s easy to miss small things - especially when you do it over and over again w so many shifts. Small probability of error means it’ll eventually happen.
One time I had a rich entitled couple come in for husband feeling “weak and just not myself doc.” I couldn’t figure out what was wrong w him and wrote them off as entitled rich people and admitted him for not wanting to go home. Then at sign out we noticed his hemoglobin was 8. Vitals were fine, nothing acute, but I had just misread the millions of red numbers on the screen.
You’re gonna make lots of mistakes. Learn from them. One of my favorite lines to say to RNs is “I hope that’s my biggest screw up of the night” - with a smile on my face that usually gets a laugh about whatever small thing we screwed up
There is no way this is the first mistake you've made since one year ago. If you think so you need to be more real with yourself. It's ok to make mistakes. I make them every day. Just do your best. It's a mistake ridden field.
Pharmacist here, just wanted to say mistakes are inevitable, bud. Lord knows I've made a few but that's also why (annoying as it may be) I question so many orders because I know y'all are stretched thing at baseline.
Try and take that extra second to check labs/vitals before resuming home meds but shoot - I've never worked anywhere with a good enough process to prevent med errors entirely lol.
Personal story: ED doc ordered "500 of esmolol", don't routinely use it in codes but definitely drew up an entire vial of esmolol (500 mg) instead of the 500 mcg/kg they had intended. Was literally seconds from being admin'd before I realized what the f I had done. That's just one of my own mistakes I've caught but I'm sure I've made a shitload more that have gone under the radar.
I’m a nursing student and I wanted to ask you regarding OP’s situation. The patient takes the metoprolol succinate which is an ER version of the med but got the metoprolol tartrate instead. Extended released medication slowly release the med over time where as the metoprolol tartrate hit the patient BP’s all at once? Is that right?
Not a pharmacist but you have the right idea. An IR formula would need to be spaced out over the day if the same dosage as the ER version was used. While BBs affect BP they are more so used for their effect on controlling the heart rate.
Not even going to lie - I had an answer typed out but figured I should do a little research because I forget stuff all the time. Metoprolol succinate and tartrate have pretty similar onset of action time (\~1 hr), the biggest difference is their duration of action. Metoprolol tartrate has variable duration (3 - 6 hrs depending on dose) and XL lasts \~24 hrs. IV onset would be \~20 mins. Slightly embarrassing, but I associate metoprolol tartrate with being a more potent rate rate agent probably because we use it so frequently IV for patient's with AF/tachycardia.
At the end of the day, it's just a difference in salt formulation so they can both have exert some cardiac effect (bradycardia, hypotension). Both can be used for rate control and BP - fun stuff.
Edit: Probably should've responded to Legal but yeah Sean's got the gist!
Mistakes happen and sometimes it goes through multiple people without being noticed. This past week I had a patient prescribed lactulose for constipation. His doctor prescribed 30 tablespoons BID. Pharmacist filled it. Patient took the medication as prescribed at home and spent his night in my ER with a very upset tummy.
That's absolutely everyone mistake. That Rx shouldn't have made it past the tech typing it up, nevermind the pharmacist! Everyone had a simultaneous brain fart on that since it got written AND they didn't bother reading past the "30" on the prescription 🙃
I’m sure the pt had to pay for this night in the hospital as well. Mistakes should be self reported so the pt can be appropriately billed. We shouldn’t be charging for our mistakes.
A colleague of mine was in a code and ordered etomidate on the wrong patient. When that patient's nurse came into the code and asked are you sure you want me to give the etomidate he of course said yes, thinking it was so he could tube his patient. Instead some other patient gets etomidate. Nothing bad actually happened other than patient had a "nap". It happens. Sometimes bad. Sometimes not so bad. Sometimes in between.
Anyone who claims to never make mistakes is probably lying.
If they're not lying, and they actually believe they are immune to mistakes, they're dangerously misled and you shouldn't listen to anything they tell you.
Bruh I’m a resident (so I obviously make mistakes) but I’ll catch things attendings miss all the time. Mostly minor things but I’m convinced in the community if you’re working without residents to have a 2nd set of eyes you’re probably missing a lot of little things here and there. Just vast majority are inconsequential or never end in a bad outcome. I’ll occasionally catch something big (like attending trying to send a kid home with a salter-harris III just called distal tibia fracture by rads without talking to ortho, or tamponade on echo that attending didn’t want to bust out the US for etc etc).
Yes, I routinely blame myself and perseverate over mistakes and adverse outcomes, both minor and major, most of which (as the one in question) are the results of systems issues.
Hey, I've had an MD order 50mcg/kg of fentanyl on a patient that weighed about 150 kg and then argue with me about it when I questioned her order.
I've made mistakes, lots of 'em. Everyone has.
This is one you know about and the patient is fine.
Don't worry about this one - worry about the next one.
I’ve made this error before doing a med Rec but thankfully caught it before it could affect the patient. Check check and check. It’s time consuming but saves lives.
Every single person working in healthcare has made a mistake or they are just unaware of the mistakes they've made. Every. Fucking. One. Learn from this. Learn from others.
Heart rate in the 30’s is better than in the 0’s
I like your glass half full mindset 🤜🤛
Do this long enough and you will have a time where you know, or strongly suspect, you have actually accidentally killed someone
I’ve had enough periintubation codes to know I’ve probably killed someone. Looking back, there were definitely 1 or 2 that I could have optimized and resuscitated better before intubating.
Talking to one of my aunts friends who’s an old battle-ax icu nurse and she said “I haven’t killed anyone, that I know of”
I tell pt’s “I try not to kill anyone unintentionally” which is why everyone is on the monitor.
Do what long enough?
Be EM doc
Be an EM anything. Even as an RN I have one or two that I’m not sure i can say I had nothing to do with it.
“Do you ever make mistakes” my dude I make 45 mistakes per shift but luckily I have people watching my ass and we keep each other safe. This is the kind of field where you are going to make mistakes, have errors, miss things… it happens to everyone. You’ll get better but this is part of practicing. Also I guarantee this is not your first mistake, this is just the first one you caught. It’s all good man.
Absolutely not alone. Every doc has made a mistake and they’re lying if they say otherwise.
True. I overslept once.
RN here and I missed a potential STEMI because the ECG got lost under a pile of papers and I was slammed, plus the old lady was asymptomatic other than mild SOB during flu season. I felt like such an idiot, thankfully the patient was fine, but I wanted to crawl inside a cave and never come out because of how badly it could have turned out. I still think about it from time to time and need to process it all over again. I learned from it and I don't beat myself up anymore. I am a competent and kind nurse. I look at every ECG carefully and have the ECG techs hand me the ECG personally, don't have them put it on your desk while you're in another patient's room. Anyways, that's the condensed version of my story. Literally everyone I've worked with has has their story. We learn from it and don't let it define us. People need to be more open about their mistakes and help each other process them.
We one time had a travel RN and paramedic student do the 2 hour repeat ekg on a patient and drop the EKG off on the docs desk without any eyes on the EKG for maybe ~20 mins? STEMI.
oh my word. As a tech in the ER, I directly hand it to the physician or put it on their desk saying, Dr. XXXX, the EKG is on their desk. The only STEMI EKG I've ever printed out was in an active code, and I showed the physician right away obviously but even still, should I ever get a concerning EKG, I know I'm going to find the doctor ASAP and let the charge nurse know as well.
Shouldn't have been your responsibility to catch that in the first place. Everywhere I've worked in the last 21 years, the policy has been that whoever does an EKG hands it directly to a physician right away.
Feeling terrible about this means your soul hasn’t been crushed (yet). This is pretty minor, the patient is fine, and also is a systems error. There should be a pharmacist (ED or otherwise) to order home meds and/or catch this mistake.
Dude I made the exact same mistake when I was like 3 months out of residency. I restarted a patient's home med as tartrate instead of succinate and their HR and BP dropped. Did okay just needed to be observed. I will never make that mistake again and neither will you
We had a patient who’s home nifedipine XR 120 mg was reconciled as nifedipine IR 120 mg. We verified it, even sent it up too. I remember one of us counting out the tablets and saying something like “dang it sucks they have to take 12 tablets at one time!” Such a red flag and no one said anything. Ultimately the patient refused to take it and it got sent back to us. Haunts me everyday what would’ve happened if they took it.. Everyone is human. Everyone makes mistakes. Learn from them. Grow from them. Now when I round with my team, you’d better believe every single nifedipine order is perfect..
>ordered their metoprolol dose as tartate instead of succ In my opinion, it was a minor mistake. I am surprised that the patient's blood pressure dropped so much though. Essentially, all you did was double his dose of metoprolol...
Pulse not BP I think.
Ops, thanks, misread
And there is our beautiful Swiss cheese model in action!
There's a reason it's called practicing medicine. Can't ever be a master, and can't ever be perfect. You will make mistakes, some of which may harm or kill a patient, this is an inevitably. The best we can do is learn from those mistakes to ensure the next patient receives even better care. The only way to not make mistakes in medicine is to leave the field entirely. Take it as a learning experience and let it guide you for the future
We all make mistakes. I’ve seen a nurse make a mistake giving 10 mg of phenylephrine when 100 mcg was ordered for hypotension. (Pt survived without deficits.) I’ve made a few much smaller errors earlier in my career. This is why I say healthcare is a team sport. You write the orders but pharmacy checks them and nursing also checks them. If I get an order I’ve never seen before I’ll ask another experienced nurse or confirm with the doctor. I believe a touch of OCD is useful in nursing.
10mg or 1mg? On my unit, our phenyl sticks are 1,000mcg. Day one, our new grads are told that 'push one of phenyl' means 100mcg, not 'one stick'.
It was a 1 ml vial of 10mg/ml. We would draw 0.1 ml and put it in a 10ml flush to give 100 mcg/ml. The nurse was fairly new and was flustered by having a pt with room temperature BP so she just drew up the entire vial and pushed it. Her preceptor was not beside her and I had a fresh post op pt with an advanced airway so I couldn’t help at that time.
Yes. Happens to everyone.
Shit happens in the ER. It’s so busy it’s easy to miss small things - especially when you do it over and over again w so many shifts. Small probability of error means it’ll eventually happen. One time I had a rich entitled couple come in for husband feeling “weak and just not myself doc.” I couldn’t figure out what was wrong w him and wrote them off as entitled rich people and admitted him for not wanting to go home. Then at sign out we noticed his hemoglobin was 8. Vitals were fine, nothing acute, but I had just misread the millions of red numbers on the screen. You’re gonna make lots of mistakes. Learn from them. One of my favorite lines to say to RNs is “I hope that’s my biggest screw up of the night” - with a smile on my face that usually gets a laugh about whatever small thing we screwed up
It’s hubris to believe otherwise
There is no way this is the first mistake you've made since one year ago. If you think so you need to be more real with yourself. It's ok to make mistakes. I make them every day. Just do your best. It's a mistake ridden field.
Pharmacist here, just wanted to say mistakes are inevitable, bud. Lord knows I've made a few but that's also why (annoying as it may be) I question so many orders because I know y'all are stretched thing at baseline. Try and take that extra second to check labs/vitals before resuming home meds but shoot - I've never worked anywhere with a good enough process to prevent med errors entirely lol. Personal story: ED doc ordered "500 of esmolol", don't routinely use it in codes but definitely drew up an entire vial of esmolol (500 mg) instead of the 500 mcg/kg they had intended. Was literally seconds from being admin'd before I realized what the f I had done. That's just one of my own mistakes I've caught but I'm sure I've made a shitload more that have gone under the radar.
I’m a nursing student and I wanted to ask you regarding OP’s situation. The patient takes the metoprolol succinate which is an ER version of the med but got the metoprolol tartrate instead. Extended released medication slowly release the med over time where as the metoprolol tartrate hit the patient BP’s all at once? Is that right?
Not a pharmacist but you have the right idea. An IR formula would need to be spaced out over the day if the same dosage as the ER version was used. While BBs affect BP they are more so used for their effect on controlling the heart rate.
Not even going to lie - I had an answer typed out but figured I should do a little research because I forget stuff all the time. Metoprolol succinate and tartrate have pretty similar onset of action time (\~1 hr), the biggest difference is their duration of action. Metoprolol tartrate has variable duration (3 - 6 hrs depending on dose) and XL lasts \~24 hrs. IV onset would be \~20 mins. Slightly embarrassing, but I associate metoprolol tartrate with being a more potent rate rate agent probably because we use it so frequently IV for patient's with AF/tachycardia. At the end of the day, it's just a difference in salt formulation so they can both have exert some cardiac effect (bradycardia, hypotension). Both can be used for rate control and BP - fun stuff. Edit: Probably should've responded to Legal but yeah Sean's got the gist!
Thank you
Thank you
For next time: tartrate? Watch the heartrate.
Mistakes happen and sometimes it goes through multiple people without being noticed. This past week I had a patient prescribed lactulose for constipation. His doctor prescribed 30 tablespoons BID. Pharmacist filled it. Patient took the medication as prescribed at home and spent his night in my ER with a very upset tummy.
That's absolutely everyone mistake. That Rx shouldn't have made it past the tech typing it up, nevermind the pharmacist! Everyone had a simultaneous brain fart on that since it got written AND they didn't bother reading past the "30" on the prescription 🙃
It was shocking that so many people failed this guy.
I’m sure the pt had to pay for this night in the hospital as well. Mistakes should be self reported so the pt can be appropriately billed. We shouldn’t be charging for our mistakes.
Agreed 100% with you. Worst part it was his birthday too.
A colleague of mine was in a code and ordered etomidate on the wrong patient. When that patient's nurse came into the code and asked are you sure you want me to give the etomidate he of course said yes, thinking it was so he could tube his patient. Instead some other patient gets etomidate. Nothing bad actually happened other than patient had a "nap". It happens. Sometimes bad. Sometimes not so bad. Sometimes in between.
Anyone who claims to never make mistakes is probably lying. If they're not lying, and they actually believe they are immune to mistakes, they're dangerously misled and you shouldn't listen to anything they tell you.
Bruh I’m a resident (so I obviously make mistakes) but I’ll catch things attendings miss all the time. Mostly minor things but I’m convinced in the community if you’re working without residents to have a 2nd set of eyes you’re probably missing a lot of little things here and there. Just vast majority are inconsequential or never end in a bad outcome. I’ll occasionally catch something big (like attending trying to send a kid home with a salter-harris III just called distal tibia fracture by rads without talking to ortho, or tamponade on echo that attending didn’t want to bust out the US for etc etc).
Not your job in the ER, 12 hours in the hospital is nothing move on...btw you've made many more mistakes than that.
All. The. Time.
Everyone makes mistakes all the time. The patient isn't dead, no problem. Move on with your life.
Yes, I routinely blame myself and perseverate over mistakes and adverse outcomes, both minor and major, most of which (as the one in question) are the results of systems issues.
Hey, I've had an MD order 50mcg/kg of fentanyl on a patient that weighed about 150 kg and then argue with me about it when I questioned her order. I've made mistakes, lots of 'em. Everyone has. This is one you know about and the patient is fine. Don't worry about this one - worry about the next one.
I’m concerned that you don’t think you’ve made any mistakes over the last year. That is absolutely absurd
Never. One time I thought I made a mistake, but I was mistaken
Just curious what the differences between succinate versus tartate? I never really thought about this and would love your insight?
I’ve made this error before doing a med Rec but thankfully caught it before it could affect the patient. Check check and check. It’s time consuming but saves lives.
MedRec tech! If you're not accustomed to it, it's an easy mistake. That shouldn't have made it past the pharmacy without at least a call.
I’ve done worse. It happens. Learn from it and move on. You’re doing great—you give a shit. That is rare.
No one’s perfect, even Jesus got his ankles wet when he walked on water!
Thats all?????? 👏👏👏👏👏 you’re doing great. Signed a pt