Talking with operating room nurse Beverly Pavelich, you can tell in an instant that she is reliving the moment.

“We had just given a lethal dose of blood thinner to a patient,” she says, tears in her eyes, as her voice catches. “I was just sick. I could just have vomited. I don’t think in my whole nursing career I have ever been so sick. It was just the worst feeling ever. I can’t even talk about it.”

But in a crowded cafeteria, this 43-year veteran nurse sits and does.

RR-2015-12-15-courage-greyscaleIt wasn’t a usual morning for Pavelich. Newly trained to give influenza immunization to her co-workers, she wasn’t going to be spending the morning in the operating room like she typically did. Instead, she was only there to help set up for a surgery.

Many surgeries require the use of blood thinner called Heparin. However, the procedure on this day wasn’t a typical one, and the crew had been told they would need one large single bag of the thinner, which was to be mixed in with a saline solution and given through IV.

“I drew up 50,000 units of Heparin to put into a 1000 ml saline bag as an irrigation solution. I hung it on an IV pole beside our supply cart at the back of the room,” she explains. “When I went to get a red label to label it, my co-worker was counting supplies with the scrub nurse standing in front of the cupboard with the labels making it difficult to get to. So as not to disturb the count (which is a critical process), I waited. Then I was called away to help with something with the patient.”

Bev left the operating room once it was ready as she was anxious to set up her immunization clinic in a conference room nearby. A few hours later, her phone rang. It was her co-worker who was assisting with the surgery.

“She asked if I had drawn up the heparin solution and hung it. She said she was sure she had seen me do it and we had discussed it. I told her I had and had left it hanging by the case cart. She said ‘It’s not there. Did you label it?’”

Pavelich remembered in that moment that she hadn’t.

“I ran back to the operating room and we realized instantly that the anesthesiologist had taken it and given the whole bag to the patient two hours earlier,” says Pavelich.

The team had assumed it was regular saline solution used in the OR as it was in the same type of bag and hadn’t been labelled differently.

“I thought I’d throw up I felt so ill,” she said, thinking back on her panic in that moment.

Instead, she and others sprang into action. An certain agent could reverse the effects of the heparin. The patient was still undergoing surgery and was only just starting to show the physical signs of the overdose with their blood not clotting quite as fast as it would at this point in the operation.

Working with the perfusionist, they ran a test that measured the clotting factor of blood. This helped them know how much reversal agent the patient would need.

“I just prayed. How could I have made such a drastic error?” Pavelich recalls. “The perfusionist assured me it was reversible and took charge so well. He just gave me a big hug as he knew how upset I was.”

By the end of the surgery, three hours later, the effects were reversed and the patient had recovered.

“It was a miracle,” Pavelich says quietly looking out towards the window, taking a moment to reflect and gather herself. “Never have I felt so bad as a nurse. I don’t ever remember making a drug error in my 40-plus years of nursing.”

The surgeon talked with the patient’s family about what had happened. For Pavelich, the immediate danger for her patient was gone, but her own personal healing had yet to begin.

“I almost quit and retired. And I thought, ‘No, I can’t go out like this. I have worked too hard to be a really good nurse my whole life’.”

Instead, she stepped in front of the OR teams that next morning, a crowd of more than 25 of her peers, and told them what happened.

“I didn’t want it told in the coffee room behind my back. So, right away I wanted to be the one to tell my story. Hiding was the last thing I wanted to do,” she says. “I felt totally safe doing it, but it was scary. I had friends supporting me and they knew it could have been anyone. And, I didn’t want this to ever happen to anybody else, so I wanted to tell them.”

Pavelich worried what would have happened if this had happened to younger nurses on her team.

“To be doing this at the beginning of your career would be just awful. At least I have a whole good career behind me that I had never done anything like this, which helped me stay confident,” she explains, “And by sharing, it tells them that this can happen to anyone.”

Pavelich knows firsthand it has happened to others. She has been on the other side of a medication errors. One of her children, while hospitalized, had three errors in five days  – one with  nearly fatal results.

“It was awful,” she says, encouraging parents and families to stay vigilant and not be afraid to question what is happening with their care. She also knows what it is like to be on the caregiver side.

“I think you have to know mistakes happen and people have to be willing to forgive,” she has learned. “There is a difference between an accident or a mistake, and continual bad care or a bad employee. I think people have to know the bad employees are dealt with, watched and reprimanded. They need to have that safety in any of their care.”

It’s for those who work hard to give good care every day that she believes strong processes need to be in place to help prevent human mistakes, especially given how complex care has become.

“When you do enough things over in your career, and do it that many times, you are eventually going to make a mistake,” she says. “Whether it is at night or you are tired. That morning, my mind wasn’t there because I was thinking about my immunization clinic. I was distracted.”

Today, in the aftermath of that fateful day, the process that put Bev on the path of that error has been strengthened. Among other changes, Heparin is no longer mixed in with regular saline bags. It is only mixed with smaller bags, so at a glance, regular saline solution can’t be mixed up with a solution mixed with other medication.

But aside from building stronger processes, Pavelich says supporting care teams who have lived the devastation of being part of a medical mistake is just as critical. And, it might not all be the same type of support. For example, for her personally, meeting the family would not have helped the healing.

“I would have felt worse. That would not have helped my healing. You would see that picture of that person for the rest of your life,” she says. But what she says is important is creating a safe zone to admit mistakes and learn.

“I felt that (that next morning),” she explains. “You have to be able to feel safe to tell your story and you need lots of support and reassurance from all your peers – be it doctors, nurses . . . Every time somebody would go to give me a hug, I would just burst into tears because you think ‘somebody could have died because of that.’ It is just such an awful feeling to make a mistake like that.”

But it was that constant support that made a difference, and continues to do so today.

“You will be more respected if you make a mistake and you tell right away. You can better live with the consequences of actions because it is much easier when not on your conscience anymore,” she says. “We are human. We all make mistakes. In a career that is long, you are going to make mistakes and we all know that.”

And she is grateful for her team helping her heal.

“No one judged me or spoke badly to me about it, which has helped, but it has taken a long time to get over it. In retelling it now, it still sends shivers down my spine.”