Mistakes

There have been many times I've made a mistake and caught myself - making me wonder how many OTHER times did it just slip through? For instance, today I was assigned a patient transferred from the medicine floor and I carefully read over the progress notes as is my habit. I noticed that the patient had originally requested do not resuscitate (DNR) which was rescinded for a procedure. I felt so proud of myself in getting the DNR back on board to ensure that things happened to the patient's wishes. The nurse in charge of the patient was aware of the DNR status. However, I then notified the nurse monitoring all the EKGs on the floor about the DNR order. She got a bright orange sticker and proceeded to identify the patient as DNR. Luckily, in that moment, a nurse came over and asked me a question about another patient. That's when I realized...I had told the monitoring nurse the wrong patient!

It would've been a potential nightmare had that patient coded and we mistakenly withheld life-saving measures thinking he desired not to be resuscitated (and clearly by then the patient would not be able to object to our inaction). The nurse probably would have picked up this error and nothing would have happened, but seeing as this was a night team signing on, unfamiliar with the patients, there was a potential for serious harm if not at the minimum serious confusion.

My lesson? Never trust my brain. Always look at the piece of paper in my hand, and do not rush important things like DNR orders.