Personal Essay Sample: My Biggest Mistake in Nursing Practice

Nursing practice, like any other process, is prone to mistakes. Blunders can happen in the day to day practice even when all the necessary mechanisms to avoid them are put in place. It is therefore, advisable to anticipate medical errors to facilitate their prompt mitigation when they occur. Medical errors in the field of nursing can happen through omission or malpractice (Kalisch, 2016). In my practice as a nurse, I have made several mistakes, some with no implications on patient care, and others with far reaching impacts to the patient care and teamwork collaboration. The worst mistake that I did was in 2015. I was managing the nursing station alone since my colleague was off duty. It was a busy day since there were three patients scheduled for surgery. I was also supposed to plan for the discharge of two other patients. On the same day, four patients from the outpatient department were sent to the wards for admission. With the bulk of work ahead of me, I set to make a plan of work to ensure that I didnt fail in any way. I decided to begin my day by attending to all the duties in their order of priority.

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I made all the necessary plans to facilitate the operation of the three patients. I called the lab to request for blood. I also called the theatre technicians to remind them of the operations. I also summoned the doctor on duty to remind him of the pending surgeries. Afterwards, I checked that the patients to be discharged were in stable conditions to get out of the hospital. This activity meant that I had to visit each patient at the bedside and review their files. In my file reviewing ward round, I discovered that one of the patients marked for discharge had not taken all the medicines prescribed to him. He looked very weak and medically unfit. His breathing rate was fast and his eyes were sunken. I rook his vital signs and found that his blood pressure was critically low. He was slightly colder than normal. I immediately embarked on critical care to stabilize the patient. The first thought that came to my mind was that the patient needed to eat. I asked the matron to order food from the kitchen for that patient to take. Unfortunately, he could not initiate the swallowing reflex which meant that I had to insert the feeding tube.

I rushed to the nursing station to collect a feeding tube. This is when the mistake happened. Instead of inserting the tube into the stomach, I directed it to the lungs. There is a very important step that is involved in this practice. Before passing any food through the tube, it is mandatory to ensure that the tube is indeed in the stomach. One is supposed to insert one end of the tube into a glass of water to test for its position in the body (Ozols &.Saunders, 2016). I skipped this step. I observed that the patient was constantly coughing but I did not pay any close attention to it. I ordered the nurse aid to prepare semi solid food so that we could feed the patient. Before I passed the food through the tube, the patient choked and became restless. For all this time, I did not realize that the tube was lodged in his lungs. It is when the nurse aid noticed mist inside the tube that I decide to check it. I was surprised with the blunder that I had done. I realized that I was only a few minute away from taking a patients life due to my mistake. I immediately pulled out the tube and let the patient breath for ten minutes. Still, we needed to feed this patient, and so I picked another tube and inserted into the correct system.

The incident did not escalate to more disaster due to the input and keenness of the nurse aid. However, the situation could have been worse if I was working alone. I attribute this mishap to a common source of nursing error: fatigue and overworking. I was in a hurry to save a dying patient who had not received attention from any other nurse. I had so much to accomplish in one day, meaning that I was not performing optimally as a nurse. Preventing the occurrence of such an error in the future requires finding a solution to the root cause. Proper duty management can be achieved through an app developed by Otrovsky et al. (2016). The app helps nurses to improve nursing care, efficiency and documentation. The app is coupled to a web-based administration system that systematically guides nurses to all processes in a care facility. With such an app, the patient in question could have been documented and proper care taken promptly. Also, the piling workload on my desk could have been cleared in time with the help of other nurses.

References

Kalisch, B. (2016). Errors of Omission: How Missed Nursing Care Imperils Patients. Journal of Nursing Regulation, 7(3), 64.

Ostrovsky, Y., Buttaro, T. M., Diamond, J., & Hayes, J. (2016). Technology and Dynamic Pathways: How to Improve Nursing Care, Documentation, and Efficiency. Iproceedings, 2(1), e31.

Saunders, R., & Ozols, A. (2016). Cost-Benefit Analysis for Direct Visual Observation of Nasogastric Enteral Feeding Tube Placement. Value in Health, 19(7), A693.