Speaking of Learning Experiences....

I intend the following as a comfort, not as a cautionary tale. If ever you feel like you've really blown it, come on back and re-read this entry.

It was one of those days with a vengeance. We were short on both sides of the staffing sheet, had a unit full of high-acuity patients, it was a weekend, and I was in charge of the floor. Any one of those things would be a recipe for suckage, but combine them all (because I am *not* a good charge nurse *at all*) and you have pure, unmitigated Hell.

It was so bad that I got on the horn and had lunch delivered, because I knew nobody would have time to even hit a vending machine.

So. It's a bad, crazy, things-going-wrong-everywhere day. One of our patients took a sudden turn for the worse and had to have a lumbar tap in order to get some cerebrospinal fluid for various tests.

Now, CSF is considered a "precious" fluid. It's hard to get, you don't want to take too much of it at once, and it's very delicate. It has to make it to the lab in, like, ten minutes or it's no good for testing.

Our patient not only was a hard tap, she had to be tapped under fluoroscopy. That means necessary exposure to X-rays, which you want to avoid if at all possible.

We sent the patient down to radiology and she had the tap done. The chart came back up with the patient, we put her to bed and stuck the chart in the rack, and went on with the day. 

(You can see where this is going, right?)

Lab samples have to be labeled in a particularly tricky way. For that reason, it's up to the nurse to label the samples on the floor, in the patient's presence, while looking at the armband on the patient's wrist. If you have a sample that's been drawn somewhere else, there are a couple of unique identifiers that are slapped onto the sample tubes, but the rest of the labeling and sending the samples to the lab are the floor nurse's responsibility.

(Now it's all coming clear, isn't it?)

The CSF that had been drawn, with great difficulty under X-ray, and with the patient heavily sedated, sat in the chart in a plastic bag for seven hours.

Seven hours.

And it was my fault. Yeah, yeah, the floor nurse should've checked the chart, but *I* was charge and had had the chart in my hands multiple times in that seven hours. I never once double-checked, as I was supposed to, that the samples had actually been sent. So, when the lab called to ask where in blazes those samples were, I was flummoxed.

Until I opened the chart. Then I was queasy.

(See what I mean about Learning Experience, Nuclear-Grade?)

I did what I had to do: I called the doc. The conversation went something like this:

Doc on phone, returning page: "This is Scott."

Me, shuddering internally: "Hey, Scotty. You wanna yell at me now, or yell at me after you find out how bad I fucked up?"

Doc: ".... ..... ......shit. Jo, what happened?"

Me: "That CSF didn't get sent. It's still in the bag on my desk."

Doc: "Oh, that's fine. We just need it for (insert name of obscure test here), and it doesn't have to be fresh for that."

Me, weak with relief: "Oh, thank God. Okay, then; sorry to scare you."

Doc: "No problem. Boy, am I glad it wasn't something important."

Me: "Meee tooo, Scotty. Me too."

I got really lucky. More importantly, our patient got really lucky: she didn't have to be exposed to ionizing radiation again, didn't have to get tapped again, and the thing that was wrong with her wasn't going to get worse with a seven-hour delay in test results.

Nevertheless, the point here is that I Fucked Up. Royally. I have been doing this, as I've pointed out in other places, for seven years. I *know* what the drill is with lab samples. I *know* how to take care of them. And yet, with the stress of the day, all of that went out the window and I made a huge, potentially damaging mistake.

Next time I'll be more paranoid. I won't assume that the patient's nurse has checked the chart; she might be too busy, or might forget. I won't relax until I see that the samples have been received by the lab and entered into the computer. I'll hand-carry the damn things down myself, charge nurse or not. 

So don't feel bad if you screw up. It happens to all of us. The best you can do is try to fix the mistake, recognize where the mistake started--because it's never just one thing; it's always a chain of events that leads to a mistake--and make plans to avoid it next time.