by Avery Thatcher
I was working a busy night shift in the ICU – we were short staffed and had a lot of patients that were really sick. There were alarms ringing almost constantly, people moving quickly or walking at Nursing Speed as I like to call it.
Nursing speed is when you walk as fast as possible without running – so that you still comply with the hospital workplace safety guidelines.
My patient was really sick, with 7 or 8 medications running at the same time through their IV’s, a ventilator breathing for them, and another machine running to help their kidneys clean their blood. Everything was temporarily in it’s precarious balance as is so common in ICU patients.
My patient’s room just happened to be across the hall from the medication cupboard and that meant I was often ask to double check the medications that needed two signatures like narcotics or insulin.
Just as my patient started to tip off the delicate balance I had them in, another nurse popped her head in and asked me to cosign the morphine dose she had pulled up for a patient. I ran to the door, verified that yes, she did indeed have the amount of morphine she said she had and that she had pulled it from the correct morphine vial. Off she went and I went back to stabilizing my patient again.
Everything returned to the semi-calm for a little bit.
But then the shit hit the proverbial fan.
A patient was crashing. They had stopped breathing and weren’t on a ventilator to help them breath.
Someone came to cover my patient so I could go help – and that’s when I saw the nurse who’s morphine dose I had checked sitting at the desk outside her patient’s window with her head in her hands. I ran into the room and saw people looking at the medication record and immediately my stomach dropped.
Because I didn’t take the time to check the doctor’s order, or find out her patient’s condition/weight/ventilation status – we had given her patient 10 times the amount of morphine they should have received. When you receive that amount of morphine – your brain decreases your desire to breathe until sometimes you stop.
I immediately spoke up and shared what had happened and the team gave the patient narcan (the antidote to morphine) It turned out that the patient was just fine with no side effects of the medication error.
I, however, was devastated.
To be honest it still haunts me. It was the most significant mistake that I’ve ever made – and I still worry about what might have happened if the mistake wasn’t addressed when it was.
However, it isn’t that moment when I felt sick to my stomach that stands out for me most that night. It’s how the other staff in the ICU treated me afterwards.
The doctor came by and squeezed my shoulders and said “one mistake doesn’t make you any less of a great nurse”.
A more experienced nurse came by my patient’s room and shared a time about her big mistake. And another nurse came by to share their big mistake. And then some of the respiratory therapists came by to do the same.
I remember saying “I wish someone would just yell at me!” – but they didn’t. Instead of adding to the shame I was clearly already feeling, they offered a safe space. They talked about the human factor errors that led to the mistake, and about what we could do differently next time to prevent this kind of mistake from happening again.
Instead of anger – I was met with compassion, understanding, and collaboration.
It is one of those moments that has changed how I view leadership and how to show compassion for others.
Actually, it’s one of the contributing stories that has led to the lantern tattoo on my arm. The lantern has cracks and breaks in the glass panels – but it is still perfectly capable of shining the light and leading the way.
The song, Leave a Light On by Tom Walker is the song I listen to to remind myself that I want to be that light for other people.
To not add onto their shame – but to provide emotional safety.
To feel like they can share what they need to say without judgement.
To gently challenge them when they’re ready.
To offer comfort during the challenging times and remind them that they don’t have to find their way out alone.
We all make mistakes. We all have regrets. So let’s surround ourselves with people who can acknowledge this in themselves, and walk the journey with us. Our lanterns may not always be the ones leading the way – but it’s truly an honour when that’s the case.
I think the best thing people can do for one another is to create emotional safety.