1. Lawson-Jonsson, Evelyn BSN, RN


Why is it so hard for good nurses to move on from errors?


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He was standing in our small utility room-under the fluorescent lights, hands on the counter, head down. I started quietly backing out, thinking he wanted privacy. "Don't go," he said, in a low, gravelly voice. He shook his head slowly, as if in disbelief: "I have to give up nursing." Seconds ticked by as I wondered what could possibly be so serious. Did he have cancer? AIDS?

Figure. Illustration... - Click to enlarge in new windowFigure. Illustration by Denny Bond.

Roger was older than many on our floor, his coal black hair woven with gray. A quiet, competent leader with over 10 years' experience at our hospital, he'd served as a medic in the Gulf Wars. He was conscientious about his responsibility to his team members and patients, his performance reviews excellent. As the head nurse on the afternoon shift, he'd arrive early to organize his duties. His staff appreciated his calming influence during the sometimes frantic pace of our med-surg unit.


At last it came out: "I almost hung the wrong blood on my patient."


The words dropped like a curtain, leaving him with his thoughts, me with mine. I eased the door closed with my foot, already reviewing policies and procedures, looking for answers to the "how" and "why."


"But you didn't," I told him.


It sounded like a platitude, and Roger's response was full of self-loathing:


"But I could have!" Never looking up, he told me that he'd taken the lab slip to the blood bank, found the unit with the patient's name on it, but somehow grabbed the wrong one. He hadn't discovered his error until he'd checked the patient's name band.


"I could have killed my patient," Roger said, his voice thick with pent-up anger.


"Yes, but you caught your error," I said. "The blood administration protocol worked! There'd be no need for those last two checks if nurses were robots, but we aren't."


He didn't respond, so I pushed on. I told him that if he were the only medical professional to ever make an error, then yes, he should quit. But he had to be aware of errors others had made.


At this, he nodded slightly.


"You're an integral part of this unit," I said. "We need you; our patients need your expertise, your compassion." I fell silent. At last he looked up at me, through moist eyes, and nodded. My cue to leave.


After report, Roger came to me and requested the next day off as a "mental health day." I noticed that he had the following two days off as well, and hoped that during this time he'd regain some balance.


On the way to my car, I stopped in the cafeteria for a cup of tea. I found a table in a corner where I could decompress from the shift. However serious his error had almost been, Roger's conclusion to quit nursing seemed utterly irrational. And trying to help him gain perspective had left me drained.


Then an experience of mine came rushing back in full color. Early in my career I'd taken a position at a new hospital. I wanted to make a good impression. Instead, I made a serious medication error. I remember the terror I felt, the mixture of shame and fear as I filled out the incident report. Later that night I lay silently crying, feeling so ashamed I didn't even tell my husband, denying myself the comfort he would have gladly offered.


The next day, as I prepared my medication tray with shaking hands, two physicians sat at the nurses' station, talking too loudly as they discussed the medication error and wondered which nurse had made it. Overhearing them, I turned to confess, feeling like a marked woman. They muttered something in my direction, shook their heads, and quickly returned to their charting.


For weeks afterward I expected to be terminated. For years I told no one about my shameful experience. My "little secret" occasionally popped up, bringing a tightness to my chest, eating away at my confidence. Later, when teaching nursing students to pass medications, I didn't use my medication error as an example; my perfectionism wouldn't allow it.


As my tea grew tepid, I began to understand why Roger's response-and my own, for all those years-seemed out of proportion to the "crime." They were. Roger's expectation of personal perfection had blurred the mirror he used to evaluate himself as a nurse. What do conscientious nurses need when we make a mistake? Time to evaluate the situation, to learn from it-and then the healing salve of compassion from those who stand beside us, and those who lead us.


On the fourth day Roger returned. When he walked off the elevator, head held high, back straight, I felt certain his time off had been beneficial. He came over to see me at the nurses' desk. This time when our eyes met he said, with a sly smile and a sharp salute, "Roger, registered nurse, reporting for duty."