Stupid Nurse Tricks.

I would never call another nurse "Stupid," but as for myself, I have pulled some doozies. I am not saying I did this but ...

There was a code called at about 2 am on a Saturday morning. I responded as I always do. The scene was not unusual.

The patient was an elderly man who had been extremely ill.

On my arrival I heard the patients nurse giving report. She said, " He has been here 3 days with bad cardiac and disease. He was being evaluated for possible open heart but the surgeon didnt think he would survive or derive much benefit. He was brady on the monitor and then went asystole. CPR had been started right away.

The CPR continued until every possible scenario had been exhausted. The room was a disaster area. Dr. Ray from ER asked the group if anyone had any other ideas. The consensus was that we had tried everything and it was time to "Call It!"

"Time of Death 0253."

Now, my job was to notify the family. I sat down in front of the computer and pulled up the patient's chart. Navigating to the patient's demographic information I saw it showed a sister as the Next of Kin. I picked up the phone, dialed the number, and listened as it rang 4 times before the sister picked up. It was almost 330 in the morning.

"Hello", the voice at the other end sounded groggy and I suspect she had been sleeping soundly.

"Hello this is Judy the supervisor at Memorial. Is this Mrs..." (I read the name from the computer information and waited for confirmation that it was in fact the person named)

Once she confirmed, I continued. I am so sorry to be calling you at this hour but your brother had an event that caused his heart rate to get very low. When the Nurse went in to evaluate his heart had stopped. We did absolutely everything we could but we were not able to bring his heart back to a normal rhythm and he has died.

After a lengthy pause, "Oh, My! He seemed to be doing so well tonight," she said.

At the very instant that she spoke, I was looking at the computer and realized, to my horror, that I had pulled up the wrong patient's chart. I had called the family of another patient, the patient in the room across the hall. He was, in fact, doing so well.

I immediately interrupted the woman on the phone and said, " Ma'am, I am so very sorry. I called you in error. Your brother is in fact doing very well and I must have pulled up the wrong chart on the computer. Please forgive me. I assure you this will NEVER happen again."

She said, "Oh Thank God! I am so glad he is OK."

After I hung up I looked around and saw the nurses aide, and the charge nurse both looking at me with what could only be described as a look of horror, maybe a little sympathy as well, but mostly just a "Thank God it was you that did that and not me." They didn't say anything. They didn't have to.

I immediately looked up the chart of the man who had actually died. I proceeded to notify his next of kin who happened to also be a sister. I made absolutely sure I was talking to the correct person.

I pulled up the reporting document and began to fill in the blanks with the details of my debacle. I chronicled the whole fiasco and then emailed my boss. I have always found it is better to tell on yourself when you make a mistake, rather than to wait for someone else to do it.

I documented a slew of Mia Culpas. I shared with the entire staff and the patients physician what I had done.

Then came the moment of truth. I had to go in and tell the patient who's sister I had inadvertently notified of his death.

What was that quote from Mark Twain? "The reports of my death have been greatly exagerated."

He listened carefully to both my telling of the tale, and my sincere apology. Then after a brief pause he looked up at me and grinned. "Was she pretty upset? I mean about me dying."

I assured him she was properly devastated.

When I reported off that morning to the oncoming supervisor I had to tell her the story. She laughed so hard I am pretty sure she was incontinent.

The moral of the story is. Everyone makes mistakes. All you can do is own it, apologize and allow yourself and others to learn from it.

I assure you I will never make a death notification again without double, triple, quadruple checking the patient's information.