[SouthernLPN2RN]

My worst mistake was when I gave a nursing home pt who'd had a hip done his pain and BP med at the same time without first checking his BP. I was usually supervigilant about checking bp's before I gave meds. Anyways, after an hour, his BP was 88/55 and I was FREAKING!!! I didn't care if it was the middle of the night, I still called the surgeon. I trended him, had him on q15 min vitals and basically prayed all night. I just knew I had killed that pt! He recovered fine, but scared me to death, especially since he couldn't communicate other than moans due to advanced dementia.

[MandyInMS]

I gave a double dose of antibiotics to a 1 y/o IM..being a fairly new nurse and NOT used to working with peds pts,I was unsure of the dosage prior giving and talked with the supervisor..I gave what I understood her to tell me to..she said I misunderstood her...talk about being scared sh!tless!! OMG..I cried,and cried, and cried some more..called the Doc, who was notorious for being a butt..and he was great..guess he could tell how 'tore up' I was about it..all ended well thank GOD..no harm to the baby..but still gives me the willies to this day.

[moia]

As a student I was on my second med day. It was a huge medical unit with never ending discharges and admissions. A new admission came in and I gave her all her meds as ordered..I never even looked at the note attached to the recovery room MAR that clearly and obviously said the patient had recieved her meds before transfer. To this day I can't believe I missed this huge note in permanent black magic marker.
I was horrified but I got lucky because the nurse before had given her the wrong dose as it had been increased on the doctors orders...we found this out when we told the doctor I had given her a second dose..he was confused because he had ordered the dose I was sobbing over. He had a good laugh, I got the scare of my life and learned a painful lesson that you should always sign the MAR BEFORE giving the med...I know nursing teachers say not to but to hell with that...I look for my place to sign and have more than once in my career discovered someone else already gave the med..especially when it is a narcotic.

I did see a doctor kill someone once , it was really awful because I had begged that doc not to give that drug because a week before he had nearly died from it. He ignored me and I refused to hang the drug so he convinced the charge nurse to do it after giving me a really hard time. It took 5 minutes to kill this poor man.
I had to go to about 5 meetings to explain why I refused a doctors order and how I knew the patient would die. Thank God for really good charting because that doc was trying to blame the nurses for his error but I had 3 really good witnesses including another doc who actually backed me up. I was really really surprised that he did but he has always been a good doc. The charge nurse who hung and infused the med really got grilled really badly by everyone. I wasn't exactly supportive either because at the time she was really obnoxious when I refused to give the med and she told me she was going to write me up and worse accused me of refusing to provide care for my patient.
Sometimes you may have to make a stand and accept the fallout. Even if the patient has no serious repercussions doesn't make you wrong, it makes the doc very lucky.

[Tweety]

Well since we're confessing. I made two mistakes that still haunt me to this day.

I had two syringes of medication, one phenergan and one saline. I color coded them with different color needles so I would know which is which. On my way to the patient's room whom I was going to give 50 mg of IM Phenergan too I stopped to fix a beeping IV. I stopped the machine and decided he needed to be flushed. And yes I flushed him with the Phenergan. Worse I turned back on his IV, which was heparin, I entered a rate of 200 cc/hr (we had very sensitive machines back then and I must have hit the last digit twice). The man was obtunded from the IV phenergan, which worried me because I was afraid he had a cerebral bleed from too much heparin, he got about 10,000 units. He woke up a couple of hours later and was fine. The day nurse called me at home to reassure me. I was devasted and wrecked forever. That was ten years ago. We now have different pumps thank goodness.

The other one was I left a heating lamp on a burn patient who was nonverbal and couldn't call to tell me to come take it off. It was only to be on for 20 minutes. The patient was in pain when I finally realized to come back and turn it off. Again I was devastated. That was about 10 years ago too.

I'm shivering remembering these horrors. I've learned that no matter how busy and frazzled I am, never ever ever ever let your guard down.

[kimmicoobug]

The experience that I had that just really shook me up was when I first came off orientation on med-surg. I had a patient on BiPap with elevated BP's. I was so focused on her BP's that I just didn't see her declining resp status. Also, they assigned me a very crusty OB nurse who floated over to be CNA. She didn't get sats on any of my patients, including this one on BiPap. At the time I felt that she must know what she was doing to not get sats. No, what it was is that they don't get sats on the PP's, so it was out of her routine. So, in the morning, the day shift RT, got a sat on her and said she was about to code. Within 15 minutes at the end of my shift, she was sent to ICU, where she lived, did not code, and eventually went home.
That taught me alot. It has taught me to be so much more assertive, to use my resources, and to not become so focused on just one piece of the entire puzzle.

[HyperRNRachel]

I'm a student and have not made any mistakes...... that is because my experiences so far have been minimal. I want to thank all of you for being brave and honest enough to post your mistakes. I now have additional information to tuck into my packed brain to help me avoid such errors. I quess my mistakes will be new ones

In all honesty, I thank you from the bottom of my heart for adding to my education.

[ktwlpn]

Originally Posted by hyperstudent

I'm a student and have not made any mistakes...... that is because my experiences so far have been minimal. I want to thank all of you for being brave and honest enough to post your mistakes. I now have additional information to tuck into my packed brain to help me avoid such errors. I quess my mistakes will be new ones

In all honesty, I thank you from the bottom of my heart for adding to my education.

We all make them-the trick is LEARNING from them....OWN YOUR MISTAKES...I can not stress that enough-the ONLY way to learn is to admit that we are responsible....Don't try to cover up-that only leads to more problems.Don't focus on making excuses-just suck it up...When I was fresh out of school working in acute care I gave a pt a double dose of lasix and potassium.I was in the room when the doc told him we were going to give him huge doses of each and why...After the unit clerk took off the order and the RN covering me signed off on them I gave the meds...A stat dose and then 4 hours later a repeat of each....Seems the clerk took the order off twice and it slipped by the RN-I assumed that since (as an LPN) I was not permitted to take off orders that I was not responsible so I was not in the habit of checking my orders.........I learned that lesson-anything involving my pt is my responsibility from the cleanliness of the room and laundry to the food ....good luck in your career

[Tweety]

Originally Posted by ktwlpn

We all make them-the trick is LEARNING from them....OWN YOUR MISTAKES...I can not stress that enough-the ONLY way to learn is to admit that we are responsible....Don't try to cover up-that only leads to more problems.Don't focus on making excuses-just suck it up...When I was fresh out of school working in acute care I gave a pt a double dose of lasix and potassium.I was in the room when the doc told him we were going to give him huge doses of each and why...After the unit clerk took off the order and the RN covering me signed off on them I gave the meds...A stat dose and then 4 hours later a repeat of each....Seems the clerk took the order off twice and it slipped by the RN-I assumed that since (as an LPN) I was not permitted to take off orders that I was not responsible so I was not in the habit of checking my orders.........I learned that lesson-anything involving my pt is my responsibility from the cleanliness of the room and laundry to the food ....good luck in your career

Excellent advice. I've never been afraid to say "I don't know", "I'm wrong" or "I made a mistake". I worked with a nurse whom we suspected gave some BP meds to the wrong patient, and the patient wasn't hers. The patients BP bottomed out and had to be given fluids rapidly and was fine. The patient even described the nurse who gave the meds, giving an adequate description. She even went into the room with me and looked the patient in the eye and said "I've never seen you or been in here, you're confused."
Scares me that there are people out there like that taking care of patients.

[heart queen]

Now, i'm sure not my worst mistakes, but last night alone, call from the day shift nurse just two hours ago, two meds I forgot to give. doesn't seem that bad, one NaHC03, one coumadin. But I've been nursing fo 9 years.

Went into work last night with only 3 hrs. of sleep off the prior night. Couldn't sleep.

It still happens is my point. could have called in.. yes, but we keep on guilting ourselves.. okay I guilt myself, How can I can I call in when wer're short just because I couldn't sleep...... look what happens.

Almost fell asleep driving home, missed two meds.

Morale... 9 years in and still making them.... own up to them and learn. I just never spent the time RECHECKING the MAR. Both were new orders around shift change.... I just signed off 24 hr. checks because I was sooo behind. Due to sleep deprivation... my own fault.

[featherzRN]

Everyone makes mistakes, it's best to just fess up and learn from them. I had one the other day that turned me crazy-there was little chance of harm to the patient but I had visions of piles of med error paperwork, meetings, etc etc etc. :P

We're an outpatient clinic and give Procrit to various patient - some are renal patients and require special instructions, the rest are not. The 'special' patients are kept in a folder so we can keep up with their orders. This gentleman (Mr. X) walks in with his shot card - I look in the book and see no 'hold' order, so I go ahead and give it. I tell him he is due to take his CBC next week, so don't forget!

I'm looking through the book to see if anyone else's shots are coming due, and what do I see? A hold order for Mr. X! It's stuck in with another patient. Yikes! I leave a message for the patient's doctor and I am on pins and needles waiting...

"Hello? Featherz? This is Dr. Y. Can you call Mr. X to tell him he needs his Procrit shot today? I am sending over the orders!". ROFL! And /Whew! I did fess up to the doctor and he thought it was very amusing. Apparently Mr. X had decided to take his blood tests a week early and that saved me from an incident report.

Then there was the time I hooked up the oxygen mask to the 'air' plug after extubating a fresh open heart. :P That mistake was noticed within minutes, the patient was fine and my old coworkers still tease me about it. I have no memory of doing this, but I am being teased about it 10 years later so I guess I must have done it.

Featherz