May were able to enjoy an international vacation together. Her tumor decreased to one half its original size in about a month. I have never felt this bad in my life, but I will make it.” Yes, Mrs. One day she said to me, “I will not lie to you. She certainly was a very sick lady for the next 2 weeks. She trusted the doctor that she would not die from the error. She said that her oncologist had told her if I had not come forth and told him of the mistake, she might not have lived. I arrived early to tell her how very sorry I was. He would treat her aggressively with agents to increase her cell counts so that she would have enough reserve to keep her counts from going down to zero. The oncologist said that she would be very, very sick for about a month but would not die from the overdose. May than normal for a patient with her condition, as she had a life expectancy of only 6 months to a year and didn’t want to live with serious side effects from the chemotherapy. When I told the oncologist about my terrible error, he stated that he had ordered a lower dose of the medication for Mrs. Today, I still remember the kindness that was bestowed on me that day. I kept thinking, “This lady is going to die and it is right at Christmas time.” You are always so careful.” Together we went through the trash and found the 4 boxes. Instead of giving me a reprimand, my manager said, “Let’s make sure that you truly gave that much of the drug. May died, there was a good chance that I would not ever be allowed to practice nursing again. Immediately, I went to the nurse manager to tell her what had happened. Since the drug was under the same classification as another that I administered regularly, I didn’t question that this might be too high a dose. I went back through the chart and realized that the dilution of the drug had been written where I had become accustomed to seeing the dose of the drug. I knew that I had given 250 mg instead of the 100 mg. I knew for a fact that I had mixed and administered two and a half times that amount. As I looked at the dose of medication the oncologist had written, I felt a lump forming in my throat. At the close of the day, I realized that I had never charted on Mrs. May went directly to see her physician and her chart went with her, so I did not have a chance to record the medications that I had given. I introduced myself and administered the chemotherapy. May had been a patient in our practice for more than a year following a diagnosis of cancer, but I had not met her. I was proud of my accomplishment and had received many compliments and best wishes for continued professional success. I was feeling especially excited because after being a registered nurse for over 25 years, I had finally completed my Bachelors of Science in Nursing. May * received more than twice the dose of chemotherapy that had been ordered for her was not just any day. Today I share my story to help us think about what we can do to reduce the possibility of errors in our practice. Some time has passed now since I made a mistake that could have easily cost my patient her life. As an oncology nurse, I am painfully aware that many of the chemotherapy agents that I administer have the potential to cause death if not administered properly. As a young nurse I was taught the 5 rights of medication administration. “Do no harm.” This ethical principle has guided my nursing practice for almost 30 years. He asked her whether she really thought she should share the story openly. With 22 students gathered in a circle in the classroom, Sarah * prefaced the reading of her story by confiding that she had read it to her husband before class. It was made clear that they needed to write something they could share with others, as we would set aside class time to read their stories aloud. Students in the Advanced Clinical Nursing class that I taught were assigned to write a paradigm case-a story that reflected an ethical dilemma that they had experienced in their clinical practice. How can nurses help to address this problem by shaping a culture of safety in healthcare? Keep reading for some helpful, safety-promoting suggestions. In international comparisons of deaths that are considered preventable by timely and effective healthcare, data showed that the United States had the highest number of preventable deaths in comparison to nine other countries, with France and Australia being the lowest ( Nolte & McKee, 2011). In 2016, researchers at Johns Hopkins found that medical errors replaced respiratory disease as the third leading cause of death ( Makary & Daniels, 2016 McMains, 2016). In 2013, the Centers for Disease Control and Prevention (CDC) ranked the top three causes of death as heart disease, cancer, and respiratory disease. Patient safety experts at Johns Hopkins have calculated that more than 250,000 deaths per year in the United States are caused by medical errors ( McMains, 2016).
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