The Decimal Point

In the present era in the medical field, it is rare for a nurse to have to actually calculate how much medication to give to a patient, but that was not the case 50 years ago.  Medications now come from the pharmacy packaged individually in correct dosages.  Sometimes syringes are even prepared with the correct amount of a medication solution to be injected.

In the mid-60s, I was a recently graduated registered nurse and was working my way through college with a part-time job on weekends.  I worked nights at the hospital from which I had graduated, and I “floated” which meant I got sent wherever they were short-staffed, and often where the action was.  One night I was assigned to a medical floor, and one of my patients had an out of control blood pressure.  I was to give her an injection of a medication to lower her blood pressure.  The amount the doctor had prescribed did not match easily with the strength of the solution sent from the pharmacy, and I had to calculate the volume to be injected.  I did this in the medication room, took it to the patient’s room and gave the injection.

The elderly woman was mostly unresponsive as it was, but a few minutes later, she died.  This resulted in a flurry of activity, including the fact that her two sisters, also elderly, were informed and arrived.  They began wailing as soon as they got off the elevator and cried out loudly all the way down the hall to her room.  We ran around hastily closing doors to minimize upset to the other patients.  The sisters threw themselves over her body sobbing, “She’s still warm.”

At some point during this chaos, I had the thought, “What if I miscalculated, and I caused her death?  What if I gave 10 times too much?”  As soon as I was able to do so, I hurried back to the medication room and checked my calculations.  I satisfied myself that I had given the correct amount and put it out of my mind.  I doubt I would remember it now, except for something that happened a couple of weeks later.

I majored in chemistry in college, and a few weeks later a homework assignment was returned to me.  One of my answers was incorrect, because I had misplaced a decimal point.  The professor, knowing I was an RN, had written on the paper, “A mistake like this could kill someone, nurse.”  A wave of nausea and self-doubt washed over me.  “What if when I had recalculated, I had made the same mistake again?”  By that time, there was no way to go back and check a third time.

So more than 50 years later, it still plagues me now and then.  In the past year, I had a conversation with another RN from my era.  She knows that she made a medication error that did result in someone’s death.  She said, “You do thousands of things right, but the thing you can’t forget is that one mistake.”  I will never know for sure if I made a mistake, but I still can’t shake it.

I guess that’s what happens when you care.