Caught a dose error before it left my hands and I am still shaking
Tam on pedsThe question
Weight based dosing, second check, and the number was wrong. Nothing reached anybody. The system worked exactly the way it is built to work.
I still sat in the car afterward for twenty minutes.
What I want to know from people further along: does the near miss stop feeling like the real thing? And did you tell anybody at the time, or is that a thing people keep?
The conversation
2 replies- Harper past the first codeRN, 10 months in, PCU
Tell someone. Not for the incident report, for you. The ones people keep are the ones that come back at three in the morning eighteen months later.
And yes, it changes. Not into nothing, into a habit. The reason you caught it is the checking you were already doing, which means the shaking and the catching are the same thing looked at from two sides.
- Devin in the ORRN, circulating in the OR, new grad program
In my room the count exists so that being wrong is a normal event with a procedure attached rather than a personal failure. Took me a while to feel that rather than know it.
Your second check is the same instrument. It did its job, and so did you, and the shaking is just what it costs to care about the outcome.
What would you tell them?
Answer from what you have seen. It posts without your name.
