I Poisoned My Patient

I was taking care of pretty sick/ unstable patient on the progressive care unit I work on. She had recently failed a swallow eval due to being hypercarbic and lethargic so she had a Dobhoff. She also happened to have a guillotine BKA which required daily dressing changes with a bleach-based (Dakin’s I think) solution that had to be mixed by pharmacy. Can you guess where this is going yet? Anyway, started my assessment on this patient with no concerns or anxieties; I actually like taking care of complex and heavy patients. I was irrigating the Dobhoff and checking placement– no prob. Until I looked back at the setup for the Dobhoff supplies and saw another bottle of sterile water for irrigation that I hadn’t used — so what had I used? I checked the bottle of solution I irrigated the Dobhoff with and sure enough it was reconstituted bleach mixture meant to be used for wet-to-dry dressing for the amputation wound. I made the patient ingest bleach. I totally freaked out- my heart dropped to my descending colon- I dreaded to tell my charge- even worse call the MD and tell him about my horrible mistake. 

My mistake happened because there was only one label on the Dakin’s (wound) solution, it was facing the wall so I couldn’t see the MAR sticker that stated it was for wound care, and it was in the same kind of container the the sterile water comes in. Luckily, because the patient had a dobhoff; it had spared her esophagus of any irritation. Also, poison control (yup-had to call poison control) stated acidity of the stomach would neutralize the bleach solution. The patient ended up being okay but in the moment after my mistake- I could not believe how bad I had fucked up- to do something like when I’m supposed to be healing this patient. I thought for sure I’d be fired. The MD was really chill about it after I called poison control and determined the patient hadn’t seriously been harmed. When I explained the situation to him (the MD), he even blamed pharmacy for not better labeling the wound solution. 

Pharmacy was petty and sent me up a new bottle of wound solution with approximately 37 bright neon stickers on the bottle that state “NOT FOR IRRIGATION”. 

Icing on the cake: I was orienting a new nurse that day. Love your podcast and all the work you do to foster a sense of solidarity in the nursing community. That’s why I feel comfortable sharing my most vulnerable story; hopefully it will make others realize that you can fuck up and still be a good nurse.

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