Nurse Gwen Cox Learns from Her Patient Safety Mistake
Summary
TLDRIn 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
- đ The nurse-patient relationship is deeply personal and can involve sharing both the worst and best moments of a person's life.
- đ©ââïž The speaker's passion for nursing was established early in life and remained unwavering.
- đš A critical medical error occurred when the speaker accidentally administered a double dose of a powerful medication.
- đ The patient's blood pressure dropped dramatically, highlighting the immediate and serious consequences of the mistake.
- đ€ Despite the error, the patient showed compassion and comforted the nurse, demonstrating the human side of healthcare.
- đ„ The incident led to a crisis of confidence for the nurse, questioning her fitness and moral right to care for others.
- đ The nurse sought grief counseling and emerged with a renewed sense of purpose to champion patient safety.
- đ The introduction of quality circles in the unit led to the development of new processes and checks to prevent similar errors.
- đ The implementation of redundancy in systems was a key strategy to improve patient safety.
- đŁïž Open dialogue and team support were crucial in handling mistakes and learning from them.
- đ” The patient, Shirley, returned later, and her forgiveness and encouragement had a profound impact on the nurse's career.
- đ 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.
Outlines
đ©ș A Nurse's Mistake and Redemption
The narrator, a nurse, shares a deeply personal story about a mistake she made early in her career that had life-threatening consequences for a patient. While working in a cardiac intensive care unit, she accidentally administered a double dose of a powerful blood pressure medication to a patient due to a moment of inattention. The error caused the patient's blood pressure to plummet, leading to a crisis. Despite the nurse's guilt and tears, the patient comforted her, saying everything would be okay. The incident led the nurse to question her fitness for the profession and seek grief counseling. Through this process, she found renewed purpose and became a champion for patient safety. She helped implement quality circles in her unit to reduce errors and improve safety protocols. Years later, she had the opportunity to apologize to the same patient, who was dying, and found closure in the patient's forgiveness and understanding.
Mindmap
Keywords
đĄNurse
đĄPatient-Nurse Relationship
đĄMedication Administration
đĄMedical Error
đĄGrief Counseling
đĄPatient Safety
đĄQuality Circles
đĄFatigue in Nurses
đĄRedundancy
đĄLearning from Mistakes
đĄChampion for Patient Safety
Highlights
The profound relationship between a nurse and a patient, characterized by love, giving, and honesty.
A personal account of growing up with the aspiration to become a nurse.
A critical incident in a cardiac intensive care unit where a nurse accidentally administered a double dose of medication.
The patient's compassionate response to the nurse's error, providing comfort and reassurance.
The emotional turmoil and self-doubt faced by the nurse after the medical error.
The nurse's decision to seek grief counseling to cope with the incident's aftermath.
A renewed sense of purpose and commitment to patient safety following the counseling.
The establishment of a Quality Circle in the unit to improve medication administration and patient care.
The introduction of processes to reduce errors and enhance safety, including fatigue management and team support.
The development of redundancy in systems to ensure double-checking and safety.
The patient's return to the unit six months later, critically ill due to heart damage.
A poignant apology and reflection by the nurse on the impact of the error and the lessons learned.
The patient's final words of forgiveness and encouragement, solidifying the nurse's commitment to patient safety.
The enduring inspiration drawn from the patient's name, Shirley, throughout the nurse's 30-year career.
The narrative's emphasis on the importance of learning from mistakes and the role of support systems in healthcare.
The transformative power of patient-staff interactions and their impact on professional growth.
Transcripts
[Music]
the relationship you develop with the
patient is one of the most loving giving
honest relationships you can
have that person has entrusted you
you've shared the worst and you share
the
best I grew up wanting to be a nurse
never wanted to be anything else
[Music]
I was probably 3 years out of nursing
school and I was working in a cardiac
intensive care unit one of my patients
had suffered a large heart attack and I
was in our mro which was open to our
nurses
station and I was laughing and talking
with my
co-workers and not really paying a lot
of attention to what I was drawing up in
the syringe I went into her room and
started injecting the medication and one
of the nurses from the um desk called
out and said Gwen look at your monitor
and her blood pressure had just
plummeted I looked down at my syringe
and I realized I had double doed her on
this very powerful blood pressure
medication I was crying and the patient
actually took my hand and comforted me
and said honey everything will be
okay I'm standing there in the back of
the room watching my
teammates try to
salvage a patient that I
harmed I had potentially killed another
human being simply because I
wasn't paying
attention it it was one of the worst
nights of my life
I'll never forget
it we were able to stabilize her um it
took about 4 hours stayed there about 6
days and then she did go
[Music]
home I questioned whether I was fit to
be a nurse you know was I morally fit to
take care of other human beings if I
could be so
careless so so I went into grief
counseling I felt renewed I felt like
okay this is my fate to be not only a
nurse but a champion for patient
safety we built one of the First Quality
circles in my unit and we looked at
medication administration how we care
for patients fatigue in nurses and when
a nurse made a mistake we had a team
that would talk with her we experienced
less errors we developed more processes
around checking we built in redundancy
into our systems that we didn't normally
have it took about 3 years to get all of
that
setup she came back to our unit about 6
months
later um and she was dying her heart was
so damaged that it just could not
sustain her and I said remember we in
the hospital before uh I'm the nurse
that gave you too much medicine and I
said I want to tell you how sorry I am
um but I also want to tell you how much
I learned and she reached up and kind of
cued my hands in hers and said honey I
told you it was going to be okay and as
long as you learned
something that was
great you know her name was
Shirley and and every time I start a new
project I think about
Charlie she has inspired me for a lot of
my 30 years in
nursing
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