Learning from my own mistakes in nursing

We all make mistakes but sometimes, the hardest part is owning up to them. Ruth Underdown describes her experience of losing a handover sheet and what happened next.

In nursing, we have access to highly confidential information about the people we care and as such, it is essential that we treat it with care.

Part of our training, and when we join organisations, involves receiving comprehensive training on our duty of care towards the information that we hold and the Caldicott principles.

The cardinal sin is to lose a handover sheet.

Last month, whilst out in the community, I lost a handover sheet.

I was horrified.

In all of the years since I qualified, I have never lost a handover sheet. On occasion, I have unintentionally left work with one in my pocket and have had to return to work to destroy it, but never have I lost one.

It had been in my pocket when I left the office to go and visit a dying patient. It wasn’t there when I returned.

It's only human to make mistakes and nurses can't always strive for perfection. What action you take leading on from your mistakes is what matters.

I hadn’t consciously taken the sheet out of my pocket during the visit. I emptied my pockets, searched my car but nothing. I retraced my steps across the car park, but since it was a wet and blustery autumn night, the chances of finding it were slim.

I went back into the office and confessed to my stupidity to my colleagues.

‘I’m going to have to go back to the patient’s home, aren’t I?’ I said, already knowing the answer.

I tried calling the family first, hoping to not have to cause them any more distress by my incompetence.

No answer. I was going to have to go back.

I got into the car and began the drive back to the patient’s home, all the while berating myself for my stupidity.

I arrived back at the house and explained my error. The family were kind and understanding and helped me look around the house just in case I had dropped it.

I apologised continuously. They were lovely and far more understanding than they needed to be.

We didn’t find it. It was truly lost.

I apologised for disturbing them again and got back into my car to drive back to the office.

Upon my return, I knew that the next steps were going to be reporting my error. I rang the Duty Manager who was understanding and told me not to worry, ‘I wasn’t the first and I certainly wouldn’t be the last to lose a handover sheet.’

Her intentions were good, but it didn’t alleviate the sinking feeling I still had in my gut.

Then there was the completion of an incident form.

These days, they are all online which allows all incidents to be recorded and audited for CQC, information governance and commissioners’ purposes.

The hardest part of admitting the error, was speaking to the patients involved.

Admitting that you have lost their personal information opens you up to the potential of them raising a complaint.

By not admitting and reporting the error appropriately, you are putting your registration at risk.

No one is perfect.

We all make mistakes and errors of judgement.

It’s how we move on from it and learn from our mistakes that is important.

I certainly reassessed my own practice when it came to handover sheets.

We now use coloured paper for handover so that if it falls out of a pocket, it’s easier to identify.

The amount of information that is placed on the sheet is restricted to only the absolutely necessary parts. This means that the amount of information that leaves the office is restricted.

It won’t guarantee that a handover sheet is never lost again but it reduces the amount of data that might be lost.

It certainly shook me, and I hope it won’t be an experience I have to go through again.

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