Nurse Gwen Cox Learns from Her Patient Safety Mistake

Summary

In this heartfelt narrative, a nurse recounts a pivotal moment in her career when a medication error caused a patient's critical condition. The patient's compassionate response inspired the nurse to champion patient safety, leading to the establishment of quality circles and improved protocols. Years later, the patient's re-admission and eventual passing solidified the nurse's commitment to learning and growth, highlighting the profound impact one patient can have on a healthcare professional's journey.

Takeaways

• 💖 The nurse-patient relationship is deeply personal and can involve sharing both the worst and best moments of a person's life.
• 👩‍⚕️ The speaker's passion for nursing was established early in life and remained unwavering.
• 🚨 A critical medical error occurred when the speaker accidentally administered a double dose of a powerful medication.
• 📉 The patient's blood pressure dropped dramatically, highlighting the immediate and serious consequences of the mistake.
• 🤝 Despite the error, the patient showed compassion and comforted the nurse, demonstrating the human side of healthcare.
• 🏥 The incident led to a crisis of confidence for the nurse, questioning her fitness and moral right to care for others.
• 📈 The nurse sought grief counseling and emerged with a renewed sense of purpose to champion patient safety.
• 🔄 The introduction of quality circles in the unit led to the development of new processes and checks to prevent similar errors.
• 🔄 The implementation of redundancy in systems was a key strategy to improve patient safety.
• 🗣️ Open dialogue and team support were crucial in handling mistakes and learning from them.
• 👵 The patient, Shirley, returned later, and her forgiveness and encouragement had a profound impact on the nurse's career.
• 📚 The nurse's experience with Shirley inspired a commitment to continuous learning and improvement in nursing practice.

Q & A

What was the speaker's childhood aspiration?

The speaker grew up wanting to be a nurse and had no other aspirations.

In what kind of unit was the speaker working when the incident occurred?

The speaker was working in a cardiac intensive care unit when the incident with the patient happened.

What mistake did the speaker make while administering medication to a patient?

The speaker accidentally administered a double dose of a powerful blood pressure medication to a patient due to not paying attention.

How did the patient react to the mistake made by the speaker?

The patient comforted the speaker, telling her that everything would be okay.

What immediate actions were taken to address the patient's plummeting blood pressure?

The speaker's teammates tried to stabilize the patient's blood pressure, which took about 4 hours.

How long did it take for the patient to recover after the incident?

The patient stayed in the hospital for about 6 days before she was able to go home.

What did the speaker question about herself after the incident?

The speaker questioned whether she was fit to be a nurse and morally fit to take care of other human beings after the mistake.

What did the speaker do to cope with the guilt and renew her commitment to nursing?

The speaker went into grief counseling and felt renewed, deciding to become a champion for patient safety.

What initiatives did the speaker and her team implement to improve patient safety?

The speaker and her team built a quality circle in their unit, looked at medication administration, addressed fatigue in nurses, and developed processes for checking and redundancy in their systems.

How did the patient's return to the hospital affect the speaker?

The patient's return, this time dying due to her heart damage, allowed the speaker to apologize and reflect on the lessons she learned, which inspired her for her 30 years in nursing.

What is the significance of the patient's name, Shirley, to the speaker?

Shirley's name is significant to the speaker as she has inspired the speaker for many of her 30 years in nursing, and the speaker thinks about her every time she starts a new project.