Didn't See an Order Today :(

  1. Patient's K+ was 5.8. I never saw the Kayexelate order until 4PM. Repeat lytes gave K+ 6.2. Needless to say, doc was flipping (at charge nurse; thank God she talked to him). Patient's K+ had been up and down over the last two weeks but not this bad. She was going to the O.R. today for a trach (intubated for last 2 weeks--bad bad COPD'er). Was NPO (tube feedings off) but still. If I had seen the order, I would have called and asked for another means of lowering the K+ (which we did, hopefully not TOO late).

    I just NEVER SAW the frickin' order! And now she's looking pretty bad. *sigh* I could go into the many reasons the Unit was NUTS today but that doesn't change anything. We're supposed to review our charts every hour for orders.

    Man, oh, man, I'm feeling like scum of the earth right now. Maybe I should be a dog walker or something....
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  2. 41 Comments

  3. by   baseline
    Oh my. I HATE those days. But dog walking won't help. Unfortunately it happens and when it happens to you there is nothing that can make you feel worse. You have all my support. It just plain hurts.
  4. by   Rustyhammer
    I hate it when that happens...and it DOES happen.
    We have all been there before...probably will again someday.
    Think of all the things you have caught that others
    had all overlooked. Feel better?
    -Russell
  5. by   SmilingBluEyes
    THIS same SORT of thing has happened to each of us who have spent any time at all in nursing. Thank goodness it was caught. I would not spend all my time berating myself tho. You owned up to it; you won't let this very mistake happen again. I feel for you. I have made mistakes and oversights myself, believe me. It happens to the best of us......all of us eventually.
  6. by   Kayzee
    Hey..your human....and we make mistakes!
  7. by   spineCNOR
    Zee, you are only human. And as for your unit's rule of reviewing charts every hour for orders- this rule is wide open for missing things when things on the unit are crazy! There should really be a better method- perhaps a rack designated for charts with new orders (if you can "train" your doctors to put them there!)
  8. by   shygirl
    I hate days like that too. You know what I did today? I forgot to do medicare charting on three people! I went back in after hours to do this. It was so busy, I was on one of the heaviest halls in the facility! i hated today!

    Shygirl
  9. by   nursedawn67
    Originally posted by baseline
    Oh my. I HATE those days. But dog walking won't help. Unfortunately it happens and when it happens to you there is nothing that can make you feel worse. You have all my support. It just plain hurts.
    I agree..you have my support too.
  10. by   Mattigan
    The only ones who never miss anything or make mistakes are the ones sitting around not doing anything. Don't be hard on yourself... it happens. The fact that it upsets you speaks of your integrity.
  11. by   kids
    Originally posted by Mattigan
    The only ones who never miss anything or make mistakes are the ones sitting around not doing anything. Don't be hard on yourself... it happens. The fact that it upsets you speaks of your integrity.
    My thoughts exactly.

    {{{Zee}}}
  12. by   plumrn
    What was it with today? I clocked in at 0645 and didn't clock out until 2100 tonight. Had 30mins for lunch and that was it as far as breaks go. So busy!
  13. by   RED_ALERT37
    PSSSTTTTTTT.... it happens and you are only proving you are human. Dont beat yourself to death over it, learn from your mistakes and move on !!!! The fact that you care and are worried about your patients proves you are a GREAT NURSE !!!
  14. by   RNforLongTime
    Zee, I know how you feel, similar things have happened to me in the past. Don't sweat it too much, you're a good nurse. Take care! Kelly

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