your worst mistake

Let’s hear ‘em.

I’ll share mine: freshly off orientation in a peds cardiac ICU. I went to pause my lipid syringe to hang an intermittent med that was incompatible. Got interrupted as I was reaching to pause the channel and when I turned back around, I paused the prostaglandin syringe instead. Baby had a ductal-dependent lesion and was pre-op 😓 PGEs were paused for about 30 min before I realized (for those who are unfamiliar, PGEs have a very short half life - about 15 min). Immediately told the fellow and he came and assessed the baby. Thank God the PDA did not close. I didn’t eat for about 24 hours. Do not think I have ever felt so awful in my life.

Happened 6 years ago and it haunts me to this day. You had better believe I now triple check my pumps and NEVER allow myself to be interrupted while manipulating drips.